Menu
MENU

Save Time at Your Visit With Our Digital Child Registration Form

  • MM slash DD slash YYYY
  • Please enter a number from 1 to 150.
  • MM slash DD slash YYYY

  • Other family members seen by us?

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Friend / Family member name

  • Who Is Responsible For Making Appointments?

  • Parent Information

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • Person Responsible For Account

  • In The Event Of An Emergency, Who Should We Contact?

  • Dental Insurance Information

  • Primary Insurance

  • MM slash DD slash YYYY

  • Secondary Insurance

  • MM slash DD slash YYYY

  • Medical and Dental History

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • Are You Allergic To Any Of The Following?

  • Did / Do your child have any of the following habits?

  • Have you ever had any of the following medical problems?

  • If yes, please explain
  • *
  • *
  • MM slash DD slash YYYY
Read Our Patient Testimonials
Rate Us
586-257-2081
Call Us Today
36150 Dequindre Rd Suite 800, Sterling Heights, MI 48310
Our Hours
Thursday9am - 6pm
Contact UsRequest an Appointment
  • Monday 9am - 6pm
  • Tuesday 9am - 6pm
  • Wednesday 9am - 4pm
  • Thursday 9am - 6pm
  • Friday Closed
  • Saturday 9am - 3pm
  • Sunday Closed