Patient Forms

It is our pleasure to make your initial visit a pleasant one.

New patients are required to fill out three forms:

  1. Patient Registration Form – Personal information including contact information and insurance details, if applicable. Please note: Patients under the age of 18 or those covered by a parent or guardian’s insurance should fill out a Child Registration Form. All others use the standard Patient Registration Form.
  2. Medical History – Details of medical and dental health history
  3. HIPAA Form – Acknowledging receipt of the Patient Notice of Privacy Practices of Preservation Dental® as required by federal regulations*

Patients of record may be required to update files periodically.

Please read through and complete each form to the best of your ability. You may fill out the form online and print it – or – print the form and fill it in legibly in black or blue ink. You cannot submit forms electronically due to the privacy practices of Preservation Dental®.

Patient Registration Form
Child Registration Form
Medical History Form
HIPAA Form
Patient Consent Form
Payment Authorization Form

If there are any questions or concerns feel free to contact the office at 248-348-1313. Bring the completed forms with you to your first visit along with your insurance information and proper identification. You can also mail the forms or drop them off prior to your appointment. The address is:

Preservation Dental®
Office of William S. Demray, DDS
371 E. Main Street
Northville, Michigan 48167
USA

Questions? Contact Us

    *It has always been our priority to protect all patient health information and maintain a strict policy of confidentiality. Federal law requires health care providers to inform patients about privacy practices.  Preservation Dental® has prepared a notice describing how information about your dental care may be used and disclosed by our office and how you may obtain access to this information. Preservation Dental® asks every patient to read the notice carefully and to sign the appropriate form indicating consent to our privacy practices.

    Patient Notice of Privacy Practices