EmailMe Form - Adult Patient Intake Form

Patient Name

Prefix First MI Last

Is there another name you prefer to be called?

Pronouns

Sex

Gender

Date of Birth

MM / DD / YYYY

Age

Home Address

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

Home Phone

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

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

Email

Employed By

Dentist

Physician

How did you hear about us?

Have we treated any family members? Please list.

Marital Status

Spousal Information

Spouse Name

Prefix First MI Last

Spouse Date of Birth

MM / DD / YYYY

Spouse Employed By

Spouse Cell Phone

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

Cell Phone Carrier (Required to receive our text messages)

Email

Dental Insurance Information
ONLY if Orthodontia is covered

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 my care and the use of records by Dr. Kaley for teaching purposes and scientific publication. Please advise Dr. Kaley of any changes in your medical or dental health while under the care of our office. Thank you!

Please sign and date if you agree to the statement above.

Clear

Signature Date

MM / DD / YYYY

1 / 2

Spousal Information

Dental Insurance Information **ONLY if Orthodontia is covered**

Medical and Dental History

Authorization

Dental Insurance Information
ONLY if Orthodontia is covered