Adult Registration Form Expedite Your Sign-In Process & Spend More Time With Our Team!

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Call Today586-977-9050
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36150 Dequindre Rd Suite 800, Sterling Heights, MI 48310

Adult Registration Form

Complete Your Adult Registration Form Online

Patient Last Name:(Required)

Middle Name:

First Name:(Required)

Prefer to be called:

Gender:(Required)

Male

Female

Your birthday:(Required)

MM slash DD slash YYYY

Age:(Required)

Please enter a number from 1 to 150.

Social Security#:(Required)

Marital status:

Single

Married

Divorced

Widowed

Separated

Other

If other:

Home Address:(Required)

City:

State:(Required)

Zip:

Email Address:(Required)

Home Phone #:(Required)

Cell Phone #:(Required)

Work Phone #:(Required)

May we send text messages to this cell phone?

Yes

Drivers License:

Employer:

How long there?

Occupation:

Employer Address:

City:

State:(Required)

Zip:

How did you find us?

Did you visit our website?

Yes

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

MM slash DD slash YYYY

Name

DOB

MM slash DD slash YYYY

Name

DOB

MM slash DD slash YYYY

Name

DOB

MM slash DD slash YYYY

Previous/Present Dentist:

Previous Dentist

Present Dentist

Previous/Present Dentist Name:

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:

MM slash DD slash YYYY

Social Security#:

Relationship:

Employer:

Secondary Insurance

Insurance Co:

Address:

City:

State:

Zip:

Phone:

Group #:

Policy #:

Policy Owner:

Date of Birth:

MM slash DD slash YYYY

Social Security#:

Relationship:

Employer:

Medical and Dental History

Do you have a personal Physician?

Yes

Physician’s Name:

Phone Number:

Last Date of Visit:

MM slash DD slash YYYY

Your current physical health is:

Good

Fair

Poor

Are you currently under the care of a physician?

Yes

Please explain:

Are you taking any prescription / over the counter drugs?

Yes

Please List Each One:

Have you ever taken any anti-osteoporosis drugs?

Yes

Which Drug, Dosage?

Have you ever been sleep tested?

Yes

Have you ever been diagnosed with sleep apnea or obstructive sleep apnea?

Yes

Has a CPAP device been recommended to you for sleep apnea?

Yes

Do you use a CPAP device regularly?

Yes

Would you be interested in an oral device to replace your CPAP mask?

Yes

Do you have a history of previous surgeries?

Yes

If so, what type surgery, when was it done and the outcome?

For Women:

Are you taking birth control pills?

Yes

Are you nursing?

Yes

Are you pregnant?

Yes

Number of weeks:

Have you ever had any of the following diseases or medical problems?

Anemia:

Yes

Asthma:

Yes

Arthritis:

Yes

Artificial valves:

Yes

Bariatric Surgery:

Yes

Blood Transfusion:

Yes

Colitis:

Yes

Diabetes:

Yes

Difficulty Breathing:

Yes

Emphysema:

Yes

Epilepsy / Seizures:

Yes

Fainting Spells:

Yes

Fever blisters:

Yes

Glaucoma:

Yes

Heart attack:

Yes

Heart murmur:

Yes

Hepatitis:

Yes

HIV+ / AIDS:

Yes

Rheumatic fever:

Yes

Shingles:

Yes

Sinus problems:

Yes

Stroke:

Yes

Ulcers:

Yes

Tuberculosis(TB):

Yes

Kidney problems:

Yes

Venereal Disease:

Yes

Heart surgery / Pacemaker:

Yes

Hemophilia / Abnormal Bleeding:

Yes

Artificial bones / Joints:

Yes

High / Low blood pressure:

Yes

Hospitalized for any reason:

Yes

Cancer / Chemotherapy:

Yes

Cardiac Surgery / Stent Surgery:

Yes

Mitral Valve prolapse:

Yes

Psychiatric Problems:

Yes

Congenital Heart Defect:

Yes

Radiation Treatment:

Yes

Severe / Frequent headaches:

Yes

Drug / Alcohol Abuse:

Yes

Are you allergic to any of the following?

Any metal:

Yes

Latex:

Yes

Aspirin:

Yes

Penicillin:

Yes

Codeine:

Yes

Plastic:

Yes

Dental Anesthetics:

Yes

Tetracycline:

Yes

Erythromycin:

Yes

Other:

Yes

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

Have you ever had a serious / Difficult problem associated with any previous dental work?

Yes

Do you have or have you ever experienced pain / Discomfort in your jaw joint (TMJ / TMD)?

Yes

Your current dental health is:

Good

Fair

Poor

Do you like your smile?

Yes

Do your gums ever bleed?

Yes

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

What Drug and Dosage?

(Required)

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.(Required)

(Required)

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.(Required)

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Read Why Our Patients Love Us

“My 3 kids (ages 8,11, &13) look forward to their visits to the dentist. They love Dr Pepa because she has the lightest hand and the best name 😉. The hygienist “Super Lisa” is just super fun & keeps them entertained as she works with them. Everyone else is always attentive & very kind.” – Ona P.

“Great experience. Everyone from front office to Dr. Pepa Was friendly and courteous. Lisa was great with a gentle touch. Explained everything she was gonna do before she did it. Definitely a team approach at this facility. Highly recommend!!” – Brad M.

“The staff is efficient and friendly, the dentist friendly and very good at her craft. I had an old silver filling replaced (they last a long time, but not forever). She painlessly numbed just that tooth and I left with a completed white filling, no facial numbness and no restrictions as to what or when I could eat next. Couldn’t have been easier unless she made house calls!” – Chuck T.

“From the friendly phone call earlier in the day to checking out at the end of my visit, dealing with Laser Dental Associates is always pleasant and efficient. Dr. Pepa was conscientious and polite as she always is and the staff are friendly and helpful. I wouldn’t trust my teeth to anyone else!” – Jackie S.

“Love Laser Dental! I went without dental care for too long due to bad experience…but finally found Laser Dental! They make sure nothing hurts! I would recommend them to anyone, especially those looking for pain free dental care!” – Rhonda J.

“I’ve been going to laser dental for the last three years. I have extreme dental anxiety from a previous office and if it wasn’t for Dr Peppa and Lisa, I would have a hard time going at all. They prioritize your comfort as much as your safety and health. I’ve had cavities filled by Dr Peppa and she truly did make it a breeze. She takes breaks and talks me …” Read More – Melissa T

“Awesome !!! Love my dentist Dr Peppa and Lisa our dental hygienist!! I have been going here for 18 years !!! Go see Lisa ! You will have a timely , carefree experience and most importantly honest recommendations. Your teeth will look beautiful after seeing Lisa every time !” – Julie E.

“Outstanding care as usual! Lisa does a terrific job.” – Mark W.

“I am very happy that I chose to come to this dentist. Everyone is nice ; from the person at front of the desk, hygienist Lisa and the dentist Laura respectful and perfection in their job! Nice work !!!” – Margarita N.

“I called Lazer Dental immediately when I broke a tooth. The office sqeezed me in that very day , and Dr. Pepa painlessly repaired my tooth with such perfection it looks like I never broke it!! Thank- you Lazer Dental!!” – Kathy C.

Rate Your Experience

Ona P.

My 3 kids (ages 8,11, &13) look forward to their visits to the dentist. They love Dr Pepa because she has the lightest hand and the best name 😉. The hygienist “Super Lisa” is just super fun & keeps them entertained as she works with them. Everyone else is always attentive & very kind.

Brad M.

Great experience. Everyone from front office to Dr. Pepa Was friendly and courteous. Lisa was great with a gentle touch. Explained everything she was gonna do before she did it. Definitely a team approach at this facility. Highly recommend!!

Chuck T.

The staff is efficient and friendly, the dentist friendly and very good at her craft. I had an old silver filling replaced (they last a long time, but not forever). She painlessly numbed just that tooth and I left with a completed white filling, no facial numbness and no restrictions as to what or when I could eat next. Couldn’t have been easier unless she made house calls!

Jackie S.

From the friendly phone call earlier in the day to checking out at the end of my visit, dealing with Laser Dental Associates is always pleasant and efficient. Dr. Pepa was conscientious and polite as she always is and the staff are friendly and helpful. I wouldn’t trust my teeth to anyone else!

Rhonda J.

Love Laser Dental! I went without dental care for too long due to bad experience…but finally found Laser Dental! They make sure nothing hurts! I would recommend them to anyone, especially those looking for pain free dental care!

Melissa T

I’ve been going to laser dental for the last three years. I have extreme dental anxiety from a previous office and if it wasn’t for Dr Peppa and Lisa, I would have a hard time going at all. They prioritize your comfort as much as your safety and health. I’ve had cavities filled by Dr Peppa and she truly did make it a breeze. She takes breaks and talks me through it all. Lisa, the hygienist, is extremely comforting, gentle and cleans so well. I would recommend them to anyone. I can’t thank them enough for helping me rebuild my trust in dental work.

Julie E.

Awesome !!! Love my dentist Dr Peppa and Lisa our dental hygienist!! I have been going here for 18 years !!! Go see Lisa ! You will have a timely , carefree experience and most importantly honest recommendations. Your teeth will look beautiful after seeing Lisa every time !

Mark W.

Outstanding care as usual! Lisa does a terrific job.

Margarita N.

I am very happy that I chose to come to this dentist. Everyone is nice ; from the person at front of the desk, hygienist Lisa and the dentist Laura respectful and perfection in their job! Nice work !!!

Kathy C.

I called Lazer Dental immediately when I broke a tooth. The office sqeezed me in that very day , and Dr. Pepa painlessly repaired my tooth with such perfection it looks like I never broke it!! Thank- you Lazer Dental!!

Visit Laser Dental Associates

We can see you as soon as tomorrow!

Call Today586-977-9050
36150 Dequindre Rd Suite 800, Sterling Heights, MI 48310
Request an Appointment