Pediatric Patient Intake Form
Welcome! To assist us in providing the most complete service, please provide the following information and health history.
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  • Patient Information

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  • Dental Insurance Coverage

  • Mother's Information

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  • Father's Information

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  • Medical and Dental History

  • 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!
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