Save Time at Your Visit With Our Digital Child Registration Form Patient Last Name:*Middle Name:First Name:*Nickname:Gender:*MaleFemaleYour birthday:* Date Format: MM slash DD slash YYYY Age:*Please enter a number from 1 to 150.Social Security#:*Home Address:*City:State:*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip:Home Phone#:*School:Grade:College:Hobbies:Sports:Previous / Present dentist*Previous DentistPresent DentistName of Previous/Present Dentist:Date of last visit:* Date Format: MM slash DD slash YYYY Other family members seen by us?NameDOB Date Format: MM slash DD slash YYYY NameDOB Date Format: MM slash DD slash YYYY NameDOB Date Format: MM slash DD slash YYYY NameDOB Date Format: MM slash DD slash YYYY Did you visit our website?YesNoWho may we thank for referring you?*Friend / Family member nameDoes your child have any learning disabilities or special needs?*YesNoIf 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?*YesNoParent InformationWho is accompanying the child today?His/Her Name:Do you have legal custody of this child?*YesNoMarital Status:*SingleMarriedDivorcedWidowedSeparatedOtherMother's Information:Step MotherGuardianName:Birthday: Date Format: MM slash DD slash YYYY Home Phone:Work Phone:Employer:Job Title:How long there?Father's Information:Step FatherGuardianName:Birthday: Date Format: MM slash DD slash YYYY Home Phone:Work Phone:Employer:Job Title:How long there?Person Responsible For AccountHis/Her Name:Home Phone:Work Phone:Relationship:Social Security#:Drivers License#:Employer:Job title:How long there?Billing Address:City:State:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip:Previous Address:City:State:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip:In The Event Of An Emergency, Who Should We Contact?His/Her Name:Relationship:Home Phone:Cell Phone:Dental Insurance InformationPrimary InsuranceOrthodontic Coverage?YesNoInsurance Co:Address:City:State:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip:Phone:Group #:Policy#:Policy Owner:Date of Birth: Date Format: MM slash DD slash YYYY Social Security#:Relationship:Employer:Address:City:State:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip:Secondary InsuranceOrthodontic Coverage?YesNoInsurance Co:Address:City:State:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip:Phone:Group #:Policy #:Policy Owner:Date of Birth: Date Format: MM slash DD slash YYYY Social Security#:Relationship:Employer:Address:City:State:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip:Medical and Dental HistoryHas your child been to the dentist before?YesNoLast Date of Visit: Date Format: MM slash DD slash YYYY Are there any dental problems that you are aware of presently?YesNoIf Yes, Explain:Does your child brush his / her teeth daily?YesNoPlease rate your child's oral health:GoodFairPoorPlease rate your child's mental health:GoodFairPoorIs your child currently under the care of a physician?YesNoChild's Physician:Phone No:Date of last visit: Date Format: MM slash DD slash YYYY Is your child taking any prescription drugs?YesNoIf Yes, Please List:Does your child need to be pre-medicated before dental treatment?YesNoWhy has your child come to the dentist today?Is your water fluoridated?YesNoHas your child ever had any pain / tenderness in his / her jaw joint (TMJ / TMDJ)?YesNoHas your child's adenoids or tonsils been removed?YesNoHas your child been informed of any missing or extra permanent teeth?YesNoDoes your child have a history of any previous surgeries?YesNoIf so, What type of surgery, when was it done and the outcome?Are You Allergic To Any Of The Following?Any metal:YesNoLatex:YesNoAspirin:YesNoPenicillin:YesNoCodeine:YesNoPlastic:YesNoDental Anesthetics:YesNoTetracycline:YesNoErythromycin:YesNoOther:YesNoPlease list any other allergies:Did / Do your child have any of the following habits?Tongue thrust:YesNoSpeech problems:YesNoNail biting:YesNoUsed pacifier?YesNoMouth breather:YesNoThumb / Finger sucking:YesNoClenching / Grinding teeth:YesNoNursing bottle habits:YesNoWere you breastfed?YesNoHave you ever had any of the following medical problems?HIV + AIDS:YesNoAnemia:YesNoAny hospital stays:YesNoAsthma:YesNoCancer:YesNoChicken pox:YesNoDiabetes:YesNoHIV / AIDS:YesNoHeart murmur:YesNoHemophilia:YesNoHepatitis:YesNoHives:YesNoKidney problems:YesNoLiver problems:YesNoMeasles:YesNoMononucleosis:YesNoSkin Rash:YesNoTuberculosis (TB):YesNoCongenital heart defect:YesNoConvulsions / Epilepsy:YesNoHandicaps / Disabilities:YesNoHearing Impairment:YesNoAbnormal bleeding:YesNoImmunizations current:YesNoMitral valve prolapse:YesNoRheumatic / Scarlet Fever:YesNoAny operations:YesNoIf yes, please explainAny stays in hospital:YesNoAre there any medical conditions or problems relating to your child that need further explanation?YesNoPlease 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.Parent/Guardian*Date* Date Format: MM slash DD slash YYYY
