36150 Dequindre, Suite 800
Sterling Heights, MI 48310
586-977-9050 / Fax 586-977-5706
Frank Rosner, D.D.S., M.S.B.A. Noelle R. Gailey, D.D.S. Matthew Papsin, DMD
Young Adult Registration Form
Print blank form to fill by hand

Please note that it is important to fill in all the fields before submitting. Please use your TAB key to move to the next field. Thank you.


Last Name* :
Middle Name : First Name* :
Nickname :
Gender :   Male   Female
DOB* :		 MM DD  YYYY
Age :
School :
Grade :
College :
Hobbies :
Sports :
Home Address* :
City * :
State* :
Zip* :
Home Phone* : --
SSN :
Other family members seen by us?
Name DOB

MM DD  YYYY

MM DD  YYYY

 MM DD  YYYY

 MM DD  YYYY
Dentist :		 Previous    Present  
 Date of last Visit: MM DD  YYYY
Who may we thank for referring you?
Friend / Family member name
Did you visit our website?
Yes   No 		       
Who is responsible for making appointments?
Name : Relationship :
Home Phone : --
   
Email* :
Cell Phone : --
Work Phone : -- Ext
   
May we send text messages to this cell phone? Yes   No
In the event of an emergency, who should we contact?

Name : Relationship :
Home Phone : --
Cell Phone : --
Parent Information
Who is accompanying the child today? Name :
Do you have legal custody of this child? Yes   No Parent's Marital Status :
  Single   Married
  Divorced   Widowed
  Separated
  Other
 
Mother's Information

Step Mother    Guardian  
 
 

Name :


DOB :		 MM DD  YYYY
Work Phone :
-- Ext
Home Phone : --
Employer :
How long at current job?
Job title :
 
 
Father's Information

Step Father    Guardian  
  
 

Name :


DOB :		 MM DD  YYYY
Work Phone :
-- Ext
Home Phone : --
Employer :
How long at current job?
Job title :
 
 
Person Responsible For Account
    
 
Name :
Relationship : Work Phone : -- Ext
Home Phone : --
Employer :
How long at current job?
Job title :
Drivers
License # :		 SSN :
Billing Address : City : State :
Zip :
 
 
Previous Address :
City :
State :
Zip :
 
 
Dental Insurance
Orthodontic Coverage? Yes   No
Primary Insurance Co
 Policy Owner's Name
Address
 Policy Owner's SSN
City
 Policy Owner's Birthday
MM DD  YYYY
State
 Relationship to Policy owner
Zip
 Policy Owner's Employer
Phone
--
Employers Address
Policy#
 City
Group #
 State
  Zip
Orthodontic Coverage? Yes   No
Secondary Insurance Co
 Policy Owner's Name
Address
 Policy Owner's SSN
City
 Policy Owner's Birthday
MM DD  YYYY
State
 Relationship to Policy owner
Zip
 Policy Owner's Employer
Phone
--
Employers Address
Policy#
 City
Group #
 State
  Zip
Medical History
Why have you come to the dentist today?
Have you experienced problems with previous dental work? Yes   No
Is your water fluoridated? Yes   No
Are you taking fluoride supplements?
 Yes   No
Have you ever had any pain / tenderness in your jaw joint (TMJ / TMDJ)? Yes   No
Do you brush your teeth daily?
 Yes   No
Do you floss your teeth daily? Yes   No
Do your gums bleed?
 Yes   No
Do you need to be premedicated before dental work? Yes   No    

Are you currently under the care of a physician?

Yes   No Physician's name :
Date of last visit :
Phone #: --
Please describe your current physical health : Good   Fair Poor Please list all drugs that you are currently taking?
Have you ever been sleep tested? Yes   No Have you ever been diagnosed with sleep apnea or obstructive sleep apnea? Yes   No
Has a CPAP device been recommended to you for sleep apnea? Yes   No Do you use a CPAP device regularly? Yes   No
Would you be interested in an oral device to replace your CPAP mask? Yes   No    
Have you ever been told that you should be medicated with a drug prior to your dental appointments?  Yes   No If so, what drug and dosage?
Do you have a history of previous surgeries? Yes   No If so, what type surgery, when was it done and the outcome?
Are you taking birth control pills? Yes   No    
Are you pregnant? Yes   No Unsure Number of weeks :
Are you nursing? Yes   No    
For orthodontic treatment please complete the following
What are the main concerns that you would like orthodontics to accomplish?
Have you ever been evaluated / had orthodontic treatment before? Yes   No
   
Have there been any injuries to your face, mouth, teeth or chin? Yes   No
Have your adenoids or tonsils been removed? Yes   No
Have you been informed of any missing or extra permanent teeth? Yes   No
Do you still have your wisdom teeth? Yes   No
Do you play any musical instruments? Yes   No
 If so, what?
Are you allergic to any of the following ?
Any metal Yes   No Latex Yes   No
Aspirin Yes   No Penicillin Yes   No
Codeine Yes   No Plastic Yes   No
Dental anesthetics Yes   No Tetracycline Yes   No
Erythromycin Yes   No Other Yes   No
Please list any other allergies:
Did / Do you have any of the following habits?

Clenching / Grinding teeth Yes   No Speech problems Yes   No
Lip sucking / Biting Yes   No Tongue thrust Yes   No
Mouth breather Yes   No Thumb / Finger sucking Yes   No
Nail biting Yes   No Used pacifier? Yes   No
Nursing bottle habits Yes   No Were you breastfed? Yes   No
Have you ever had any of the following medical problems?
Abnormal bleeding Yes   No Anemia Yes   No
Any hospital stays Yes   No Asthma Yes   No
Cancer Yes   No Chicken pox Yes   No
Congenital heart defect Yes   No Convulsions / Epilepsy Yes   No
Diabetes Yes   No HIV/AIDS Yes   No
Handicaps / Disabilities Yes   No Hearing Impairment Yes   No
Heart murmur Yes   No Hemophilia Yes   No
Hepatitis Yes   No Hives Yes   No
HIV + AIDS Yes   No Immunizations current Yes   No
Kidney problems Yes   No Liver problems Yes   No
Measles Yes   No Mononucleosis Yes   No
Mitral valve prolapse Yes   No Rheumatic / Scarlet Fever Yes   No
Skin rash Yes   No Tuberculosis (TB) Yes   No

Please discuss any serious medical problems you've experienced .
Is there anything you would like to discuss with the doctor privately? Yes   No
* I understand I am responsible (if 18 yrs or older) for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance or my parent's insurance does not cover.
Patient Signature*

Date :

Parent / Guardian Signature (If necessary)

Date :

* I agree that in the event that Laser Dental Associates is forced to initiate litigation proceedings to enforce collection of this account, I am responsible for all court costs and attorney fees associated with such collecting any balance owed by myself to Laser Dental Associates. I further agree to the venue of Livingston County for any necessary litigation.
* I affirm that the information I have given is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence, and is being submitted over a secure server where my information will remain confidential and secure. It is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need.
Signature of Patient and / or Parent / Guardian*

Date :

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