Medical Health History & Additional Forms
In Lansing, Ann Arbor and Brighton, Michigan

Before we are able to conclusively diagnose or treat any dental condition you have, it is critical that we have all the relevant information about your medical and dental history.

Below is a complete list of downloadable forms we ask our patients to read and fill out before coming in for appointments. When you schedule your appointments with Dr. DiStefano and Dr. Nguyen, one of our family/cosmetic dentists or staff members will tell you which of these forms you need to read, fill out, sign (if necessary), and bring with you to your next visit with us.

• Young Adult: Medical history for children up to the age of 12
• Adult Medical History: Medical history of patients 13 and older
• Dental/Medical History: For TMJ clients ONLY
• TMJ Questionnaire: ONLY for TMJ patients of all ages
• MRI: MRI Information Form
• Notice of Privacy Practices: HIPPA Brochure given to patients at a consultation appointment regarding disclosure policies
• Limited Dental Warranty: Given to a patient at a restorative appointment

" The dental procedures we specialize in enhance our
patients' look and their quality of life! "

If you are located in the Lansing, Michigan areas and are ready to schedule a consultation with us, please contact us today!