EmailMe Form - Pediatric Patient Intake Form

Patient Information

Patient Name

First MI Last

Is there another name you prefer to be called?

Pronouns

Sex

Gender

Date of Birth

MM / DD / YYYY

Age

Patient Lives with

School

Grade

Do you have any siblings? Please list names and ages.

Please list any family members we have treated.

Dentist

Physician

How did you hear about us?

Caregiver 1 Information

Name

Prefix First MI Last

Date of Birth

MM / DD / YYYY

Home Address

Street Address City State / Province / Region Postal / Zip Code

Cell Phone

### - ### - ####

Cell Phone Carrier (Required to receive our text messages. Ex: Sprint; Verizon)

May we send you text messages to confirm appointments?

Yes

No

Home Phone

### - ### - ####

Email

Employed By

Caregiver 2 Information

Name

Prefix First MI Last

Date of Birth

MM / DD / YYYY

Home Address

Street Address City State / Province / Region Postal / Zip Code

Cell Phone

### - ### - ####

Cell Phone Carrier (Required to receive our text messages)

May we send you text messages to confirm appointments?

Yes

No

Home Phone

### - ### - ####

Email

Employed By

Dental Insurance Information
ONLY if it includes Orthodontia

Dental Insurance Name AND Claims Mailing Address (Located on the back of your card)

Name of Primary Insured Carrying the Policy

Insurance ID or SSN# if applicable

Group/Plan #

Medical and Dental History

Dental History
Check all that apply

When was your last dental check up?

What concerns do you or your dentist have about your teeth?

Have you ever had Orthodontic treatment? If yes, when and with whom?

Medical History
Check all that apply

Please list any allergies to medications.
Do you have any diseases, a condition, or problem not listed above that you think I should know about?

Authorization

I authorize the release of medical and dental information to insurance carriers and to other health care providers involved in the care of this patient and the use of records by Dr. Kaley for teaching purposes and scientific publication. Please advise Dr. Kaley of any changes in your child's medical or dental health while under the care of our office. Thank you!

Please sign if you agree to the statement above.

Clear

Name of Signer Printed

Signature Date

MM / DD / YYYY

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Patient Information

Caregiver 1 Information

Caregiver 2 Information

Dental Insurance Information **ONLY if it includes Orthodontia**

Medical and Dental History

Authorization

Dental Insurance Information
ONLY if it includes Orthodontia