Dr. Daniel Kaler, D.D.S., P.C.
Practice Limited to Orthodontics
Daniel L. Kaler, D.D.S.
Brenda F. Dick, D.D.S.

New Patient Child Forms

Good Morning, Today is Friday, May 09, 2008 it is now 10:08:15 AM

Patients Last Name, First Name, Middle
Patients E-Mail Address :
Preferred to be called Sex
Home Address
City State Zip

Patient Resides With  

Mother Father
Both Other  
Home Phone Age Birth date
School Grade
Phone Number to Reach Someone During the Day

Please describe your child's orthodontic
problem in your own words

Patients Interests
Your child's general dentist's name Referred By
Names and Ages of patient's brothers and sisters
Has anyone in the family had braces?   YES   NO
with whom:
Date of last dental exam:

Parents
Maritial
Status

 Married Widowed
Separated Single
Divorced Remarried
Parents and Account Information

Father     
Name  
Address  
City, State, Zip , 
,
Phone  
SSN  
Employer's Name  
Business Address  
City, State, Zip  ,  
,
Business Phone  
Occupation  

Mother     

Name  
Address  
City, State, Zip  ,  
,
Phone  
SSN  
Employer's Name  
Business Address  
City State, Zip  
,
Business Phone  
Occupation  

Other Responsible Person     

Name  
Address  
City, State, Zip  ,  
,
Phone  

Medical History

Physician's Name  
Address  
City, State, Zip  ,  
,
Phone  
  NO YES
Has your child experienced any health problems?
     Explain :
Any major change in your child's health recently?
     Explain :
Is your child currently under a physicians care?
     Explain :
Is your child currently taking medications?
     Explain :
Is your child allergic to any medications?
     Explain :
Has your child received a blood transfusion?
     Explain :
Have your child's tonsils or adenoids been removed
     Explain :
Has your child been in a risk group for AIDS?
     Explain :
Does your child require antibiotics before dental TX
     Explain :
Please check if your child has had any of the following conditions:
  NO YES
Heart Murmur
Heart Surgery
Developmental Disorder
Asthma
Hepatitis
Diabetes
Tuberculosis
Growth Disorders
Emotional Problems
Frequent Headaches
Bone Disorders
Mouth Breather
Is there any condition or problem
that you think we should know about?
Comments:
Dental History
Frequency of Dental Checkups Twice a year
Once a year
Only if a problem exists
  NO YES
Is there any unfinished care to be completed with your child's dentist?
     Explain:
Has your child had any face or dental injuries?
     Explain :
Is there a history of thumb or finger sucking?
     Stopped?
Does your child play any musical instrument?
     What instrument?
Has your child consulted an orthodontist previously?
     With whom?
Have teeth (either primary or permanent) been removed?
 
Has your child had any previous orthodontic treatment?
     With whom?
Is there any other information that may be helpful?
Insurance Information
Do you have orthodontic insurance :   YES         NO
     A dental insurance policy is a contract between the insured and the insurance company.  Our professional services are rendered and charged directly to the patients account and the patient or person responsible for the account is responsible for payment of all fees incurred.  For your convenience, we will gladly assist you in submitting insurance claim forms from your insurance carrier pertaining to any charge for care in our office.  If you wish assistance, we ask that you provide us with claim forms to your insurance carrier on your first visit.  Otherwise we will assume you are submitting all claims to your insurance carrier.  We will accept assignment of benefits from your insurance company if possible.
Name of insured : (employee)
SS#
Date of Birth
Name of insurance Company
Group #
   
Name of insured : (employee)
SS#
Date of Birth
Name of insurance company
Group #

                     

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