Child Registration Form Discover A Dentist Office That Cares About Your Convenience

Fill out your child’s paperwork online
Take advantage of our relaxing dental care
Save time in the office & meet our team sooner

Call Today586-257-2081
Request an Appointment

36150 Dequindre Rd Suite 800, Sterling Heights, MI 48310

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Save Time at Your Visit With Our Digital Child Registration Form

Patient Last Name:(Required)

Middle Name:

First Name:(Required)

Nickname:

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)

Home Address:(Required)

City:

State:(Required)

Zip:

Home Phone#:(Required)

School:

Grade:

College:

Hobbies:

Sports:

Previous / Present dentist(Required)

Previous Dentist

Present Dentist

Name of Previous/Present Dentist:

Date of last visit:(Required)

MM slash DD slash YYYY

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

Did you visit our website?

Yes

Who may we thank for referring you?(Required)

Friend / Family member name

Does your child have any learning disabilities or special needs?(Required)

Yes

If Yes Explain:

Who Is Responsible For Making Appointments?

His/Her Name:(Required)

Relationship:(Required)

Email address:(Required)

Home Phone:(Required)

Cell Phone:(Required)

Work Phone:(Required)

May we send text messages to this cell phone?(Required)

Yes

Parent Information

Who is accompanying the child today?

His/Her Name:

Do you have legal custody of this child?(Required)

Yes

Marital Status:(Required)

Single

Married

Divorced

Widowed

Separated

Other

Mother's Information:

Step Mother

Guardian

Name:

Birthday:

MM slash DD slash YYYY

Home Phone:

Work Phone:

Employer:

Job Title:

How long there?

Father's Information:

Step Father

Guardian

Name:

Birthday:

MM slash DD slash YYYY

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

Insurance Co:

Address:

City:

State:

Zip:

Phone:

Group #:

Policy#:

Policy Owner:

Date of Birth:

MM slash DD slash YYYY

Social Security#:

Relationship:

Employer:

Address:

City:

State:

Zip:

Secondary Insurance

Orthodontic Coverage?

Yes

Insurance Co:

Address:

City:

State:

Zip:

Phone:

Group #:

Policy #:

Policy Owner:

Date of Birth:

MM slash DD slash YYYY

Social Security#:

Relationship:

Employer:

Address:

City:

State:

Zip:

Medical and Dental History

Has your child been to the dentist before?

Yes

Last Date of Visit:

MM slash DD slash YYYY

Are there any dental problems that you are aware of presently?

Yes

If Yes, Explain:

Does your child brush his / her teeth daily?

Yes

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

Child's Physician:

Phone No:

Date of last visit:

MM slash DD slash YYYY

Is your child taking any prescription drugs?

Yes

If Yes, Please List:

Does your child need to be pre-medicated before dental treatment?

Yes

Why has your child come to the dentist today?

Is your water fluoridated?

Yes

Has your child ever had any pain / tenderness in his / her jaw joint (TMJ / TMDJ)?

Yes

Has your child's adenoids or tonsils been removed?

Yes

Has your child been informed of any missing or extra permanent teeth?

Yes

Does your child have a history of any previous surgeries?

Yes

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

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 allergies:

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

Tongue thrust:

Yes

Speech problems:

Yes

Nail biting:

Yes

Used pacifier?

Yes

Mouth breather:

Yes

Thumb / Finger sucking:

Yes

Clenching / Grinding teeth:

Yes

Nursing bottle habits:

Yes

Were you breastfed?

Yes

Have you ever had any of the following medical problems?

HIV + AIDS:

Yes

Anemia:

Yes

Any hospital stays:

Yes

Asthma:

Yes

Cancer:

Yes

Chicken pox:

Yes

Diabetes:

Yes

HIV / AIDS:

Yes

Heart murmur:

Yes

Hemophilia:

Yes

Hepatitis:

Yes

Hives:

Yes

Kidney problems:

Yes

Liver problems:

Yes

Measles:

Yes

Mononucleosis:

Yes

Skin Rash:

Yes

Tuberculosis (TB):

Yes

Congenital heart defect:

Yes

Convulsions / Epilepsy:

Yes

Handicaps / Disabilities:

Yes

Hearing Impairment:

Yes

Abnormal bleeding:

Yes

Immunizations current:

Yes

Mitral valve prolapse:

Yes

Rheumatic / Scarlet Fever:

Yes

Any operations:

Yes

If yes, please explain

Any stays in hospital:

Yes

Are there any medical conditions or problems relating to your child that need further explanation?

Yes

Please explain:

(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)

The parent or guardian who accompanies the child is responsible for payment at the time of service unless prior arrangements have been approved.(Required)

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.(Required)

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(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 Today586-257-2081
36150 Dequindre Rd Suite 800, Sterling Heights, MI 48310
Request an Appointment