36150 Dequindre, Suite 800
Sterling Heights, MI 48310
Get Directions
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.

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 :
Prefer to be called :
Sex : Male Female
*Your birthday:
Age:
*Social Security# :
Marital Status : Single Married
Divorced Widowed
Separated Other
If Other:
*Home Address:
City :
State :
Zip :
*Email address :
*Home Phone #: ( )- -
*Cell Phone #: ( )- -
Work Phone #: ( )- - -
May we send text messages to this cell phone? Yes No
Drivers License :
Employer :
How long there ?
Occupation :
Employer Address :
City :
State :
Zip :
How did you find us?
Did you visit our website? Yes No
Who may we thank for referring you?
What is the best number to reach you at?
( )- -
What is the best time to reach you?
Other family members seen by us?
Name DOB
Previous/Present Dentist:
Date of Last Visit :
Spouse Information
Spouse's Name :
Date of Birth :
Social Security# :
Drivers License #:
Employer :
Work Phone : ( )- - -
Person Responsible For Account
His/Her Name :
Relationship
Social Security# :
Drivers License #:
Billing Address :
City :
State :
Zip :
Home Phone : ( )- -
Work Phone : ( )- - -
Employer :
In The Event Of An Emergency, Who Should We Contact?
His/Her Name :
Relationship
Home Phone : ( )- -
Cell Phone : ( )- -
Work Phone : ( )- - -
Dental Insurance Information
Primary Insurance -
Insurance Co :
Address :
City :
State :
Zip :
Phone : ( )- -
Group # :
Policy# :
Policy Owner :
Date of Birth :
Social Security# :
Relationship :
Employer :
Secondary Insurance -
Insurance Co :
Address :
City :
State :
Zip :
Phone : ( )- -
Group # :
Policy# :
Policy Owner :
Date of Birth :
Social Security# :
Relationship :
Employer :
Medical History
Do you have a personal Physician? Yes No
Physician’s Name :
Phone No: ()--
Date of last visit :
Your current physical health is : Good Fair Poor
Are you currently under the care of a physician? Yes No
Please explain :
Are you taking any prescription / over the counter drugs? Yes No
Please List Each One :
Have you ever taken any anti-osteoporosis drugs? Yes No
Which Drug, Dosage?
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
Do you have a history of previous surgeries? Yes No
If so, what type surgery, when was it done and the outcome?
For Women :
Are you taking birth control pills? Yes No
Are you nursing? Yes No
Are you pregnant? Yes No
Number of weeks :
Have you ever had any of the following diseases or medical problems?
Anemia Yes No
Asthma Yes No
Arthritis Yes No
Artificial valves Yes No
Bariatric Surgery Yes No
Blood Transfusion Yes No
Colitis Yes No
Diabetes Yes No
Difficulty Breathing Yes No
Emphysema Yes No
Epilepsy / Seizures Yes No
Fainting Spells Yes No
Fever blisters Yes No
Glaucoma Yes No
Heart attack Yes No
Heart murmur Yes No
Hepatitis Yes No
HIV+ / AIDS Yes No
Rheumatic fever Yes No
Shingles Yes No
Sinus problems Yes No
Stroke Yes No
Ulcers Yes No
Tuberculosis(TB) Yes No
Kidney problems Yes No
Venereal Disease Yes No
Heart surgery / Pacemaker Yes No
Hemophilia / Abnormal Bleeding Yes No
Artificial bones / Joints Yes No
High / Low blood pressure Yes No
Hospitalized for any reason Yes No
Cancer / Chemotherapy Yes No
Cardiac Surgery / Stent Surgery Yes No
Mitral Valve prolapse Yes No
Psychiatric Problems Yes No
Congenital Heart Defect Yes No
Radiation Treatment Yes No
Severe / Frequent headaches Yes No
Drug / Alcohol Abuse Yes No
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 medications that you are allergic to :
Dental History
Why have you come to the dentists today?
Are you currently in pain? Yes No
Have you ever had a serious / Difficult problem associated with any previous dental work? Yes No
Do you have or have you ever experienced pain / Discomfort in your jaw joint (TMJ / TMD)? Yes No
Your current dental health is : Good Fair Poor
Do you like your smile? Yes No
Do your gums ever bleed? Yes No
How many times a week do you floss?
How many times a day do you brush?
Type of bristles? Hard Medium Soft
Have you ever been told that you should be medicated with a drug prior to your dental appointments? Yes No
What Drug and Dosage?
* 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 understand that the information that 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, with my informed consent, any necessary dental services I may need during the diagnosis and treatment.
*Signature
Date
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Laser Dental Associates
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"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."
Patient Reviews about Dr. Frank Rosner
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.
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