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36150 Dequindre, Suite 800
Sterling Heights, MI 48310
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586-838-2017 / Fax 586-977-5706

Frank Rosner, D.D.S., M.S.B.A. Dentist Sterling Heights - Middle Bullet 1

Laura Pepa, D.D.S.

Cerec

Crown

Bridge

Veneers

Dental Care

Dentures

Root Canal

Implants

Young Adult Registration Form

Please note that it is important to fill in all the fields before submitting. Thank you.

Patient *Last Name :
Middle Name :
*First Name :

Nickname :
Gender:	Male Female
*Your birthday:
Age:
*Social Security# :

*Home Address:
City :
State :
Zip :

*Home Phone #:

( )- -

School :
Grade :
College :
Hobbies :
Sports :

Previous Present Dentist :
Date of Last Visit :

Other family members seen by us?
Name	DOB

Did you visit our website?	Yes No
Who may we thank for referring you?
Does your child have any learning disabilities or special needs?	Yes No

If Yes Explain :

Who Is Responsible For Making Appointments?
His/Her Name :
Relationship
*Email address :
Home Phone :	( )- -
Cell Phone :	( )- -
Work Phone :	( )- - -

May we send text messages to this cell phone?

Yes No

In The Event Of An Emergency, Who Should We Contact?
His/Her Name :
Relationship
Home Phone :	( )- -
Cell Phone :	( )- -

Parent Information
Who is accompanying the child today?
His/Her Name :

Do you have legal custody of this child? Yes No

Marital Status :	Single	Married
	Divorced	Widowed
	Separated	Other
If Other:

Mother's Information : Step Mother Guardian

Name :
Birthday :
Home Phone :	( )- -
Work Phone :	( )- - -
Employer :
Job title :
How long there?

Father's Information : Step Mother Guardian

Name :
Birthday :
Home Phone :	( )- -
Work Phone :	( )- - -
Employer :
Job title :
How long there?

Person Responsible For Account
His/Her Name :
Home Phone :	( )- -
Work Phone :	( )- - -
Relationship
Social Security# :
Drivers License #:
Employer :
Job title :
How long there?

Billing Address :
City :
State :
Zip :

Previous Address :
City :
State :
Zip :

Dental Insurance Information
Primary Insurance -
Orthodontic Coverage? Yes No
Insurance Co :

Address :
City :
State :
Zip :

Phone :	( )- -
Group # :
Policy# :
Policy Owner :
Date of Birth :
Social Security# :
Relationship :
Employer :

Address :
City :
State :
Zip :

Secondary Insurance -
Orthodontic Coverage? Yes No
Insurance Co :

Address :
City :
State :
Zip :

Phone :	( )- -
Group # :
Policy# :
Policy Owner :
Date of Birth :
Social Security# :
Relationship :
Employer :

Address :
City :
State :
Zip :

Medical and Dental History
Why have you come to the dentist today?

Have you experienced problems with previous dental work?

Yes No

Please explain :

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 :
Phone No:	()--
Date of last visit :

Your current physical health is : 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

Which Drug, 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 nursing?	Yes No

Are you pregnant? Yes No Unsure
Number of weeks :

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?
Tongue thrust	Yes No
Speech problems	Yes No
Nail biting	Yes No
Used pacifier?	Yes No
Mouth breather	Yes No
Thumb / Finger sucking	Yes No
Clenching / Grinding teeth	Yes No
Lip sucking / Biting	Yes No
Nursing bottle habits	Yes No
Were you breastfed?	Yes No

Have You Ever Had Any Of The Following Medical Problems?
HIV + AIDS	Yes No
Anemia	Yes No
Any hospital stays	Yes No
Asthma	Yes No
Cancer	Yes No
Chicken pox	Yes No
Diabetes	Yes No
HIV / AIDS	Yes No
Heart murmur	Yes No
Hemophilia	Yes No
Hepatitis	Yes No
Hives	Yes No
Kidney problems	Yes No
Liver problems	Yes No
Measles	Yes No
Mononucleosis	Yes No
Skin rash	Yes No
Tuberculosis (TB)	Yes No
Congenital heart defect	Yes No
Convulsions / Epilepsy	Yes No
Handicaps / Disabilities	Yes No
Hearing Impairment	Yes No
Abnormal bleeding	Yes No
Immunizations current	Yes No
Mitral valve prolapse	Yes No
Rheumatic / Scarlet Fever	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 :
Parent / Guardian Signature:


*	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	Date

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Laser Dental Associates

Mary D.

"Love this Dentist!

I've been going to Laser Dental for a long time. They are so friendly and gentle while cleaning my teeth. The office is VERY clean! I couldn't say enough about this place. I'll continue being a long time patient."

Click here to see ratings of this dental office from other patients in Sterling Heights.

36150 Dequindre,
Suite 800, Sterling Heights, MI 48310
Phone : 586-838-2017
Fax : 586-977-5706

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Laser Dental Associates Located at 36150 Dequindre, Suite 800, Sterling Heights, MI, 48310, United States. Phone: +1 586-838-2017. www.laserdentalassociates.com