Info from You

The forms below are downloadable pdf documents that will help you give us the information we need to administratively complete your care. Click on the link, download the form, print the form, fill it out, and then bring it or mail it to our office. (The pdf forms listed below are viewable through Adobe Reader, which is often pre-installed on computers. If you need a copy or a more recent version of this free application, please go to the Adobe web site.)

For New Patients:

• Welcome Form (pdf 94k)
• Registration Form (pdf 98k)
• Important Authorizations (pdf 97k)
• Financial Policy (pdf 102k)
• Medical and Dental Records Release (pdf 94k)
• U of M Dental Clinics Registration (pdf 26k)
• U of M Dental Clinics Medical and Dental Information Questionnaire (pdf 96k)

Patients with Medicare also need to complete the NEMB form:

• NEMB Form (pdf 91k)
• Advance Beneficiary Notification (pdf 91k)

Moving? Changing insurance coverage? Please complete our Change of Information form:

• Change of Information Form (pdf 94k)

Consent Forms:

• Consent for Oral Surgical Treatment in Patients who Have Received Intravenous Bisphosphate Drugs (pdf 124k)
• Consent for Temporomandibular Jaw Joint Surgery (pdf 55k)
• Consent for Treatment to Repair Facial/Dental Injury (pdf 49k)
• Consent for Bone Grafting Procedure (pdf 93k)
• Consent for Biopsy Procedure (pdf 41k)
• Consent for Arthrocentesis of the Temporomandibular Joint (TMJ) (pdf 67k)
• Consent for Orthognathic Surgery (pdf 140k)
• Consent for Temporomandibular Joint Reconstruction with the TMJ Concepts Patient-fitted Reconstruction Prosthesis (pdf 186k)
• Informed Consent for Oral Surgery and Anesthesia (pdf 124k)

Pre-Anesthetic Instructions [Not yet posted on web site.]