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

Child 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
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 :
In The Event Of An Emergency, Who Should We Contact?
His/Her Name :
Relationship
Home Phone : ( )- -
Cell Phone : ( )- -
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
Has your child been to the dentist before? Yes No
Last Date of Visit :
Are there any dental problems that you are aware of presently? Yes No
If Yes, Explain :
Does your child brush his / her teeth daily? Yes No
Please rate your child's oral health : Good Fair Poor
Please rate your child's mental health : Good Fair Poor
Is your child currently under the care of a physician? Yes No
Child's Physician :
Phone No: ()--
Date of last visit :
Is your child taking any prescription drugs? Yes No
If Yes, Please List:
Does your child need to be pre-medicated before dental treatment? Yes No
Why has your child come to the dentist today?
Is your water fluoridated? Yes No
Has your child ever had any pain / tenderness in his / her jaw joint (TMJ / TMDJ)? Yes No
Has your child's adenoids or tonsils been removed? Yes No
Has your child been informed of any missing or extra permanent teeth? Yes No
Does your child have a history of any previous surgeries? Yes No
If so, What type of surgery, when was it done and the outcome?
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 your child 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
Any operations Yes No
Any stays in hospital Yes No
Are there any medical conditions or problems relating to your child that need further explanation? Yes No
Please explain :
* 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 understand that it will be held in the strictest of confidence, over a secure server where it will remain confidential. I understand it is my responsibility to inform this office of any changes in my child's medical status. I also authorize the dental staff to perform the necessary dental services that my child may need.
The parent or guardian who accompanies the child is responsible for payment at the time of service unless prior arrangements have been approved.
*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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