Online Orthodontic Referral Form
Daniel L Kaler DDS, PC
Referring Dentist Name:
*
Name of Dentist Referring this patient
Name of Practice:
Please enter practice name if different than above named referral
Patient Name:
*
First Name
Last Name
Patient Date of Birth:
*
-
Month
-
Day
Year
Date
Date of Last Dental Checkup:
*
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Month
-
Day
Year
Date
Is there any unfinished dental work to be done for this patient?
NO
YES - Please Briefly describe planned dental work
Reason For This Referral?
Comprehensive Orthodontic Evaluation
Crowding
Cross Bite
Excessive OJ
Excessive OB
Underbite
Impaction
Other Problem, Please describe below
Panoramic X-Ray Available?
*
NO - Patient Does Not have a recent panoramic on file
Yes - A Copy will be sent to braces@drkaler.com-Please Include Date:
Yes - A jpeg image will be uploaded below-Please Include Date:
Date of Any Attached or Emailed X-Rays
-
Month
-
Day
Year
Date X-Ray was taken in your office
X-Ray Image File(s)
Browse Files
Drag and drop files here
Choose a file
Drag and drop or copy and paste an image file to this box.
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of
Contact Options:
*
Please Contact the Responsible Party with the Information Provided to schedule a New Patient Evaluation
The Patient/Responsible Party has been asked to contact your office to schedule a New Patient Evaluation
Responsible Party Information:
Self/Patient
Father
Mother
Other-Please describe below
Responsible Party Name:
First Name
Last Name
Responsible Party Contact Phone#
Responsible Party Contact Email
example@example.com
Please Note:
We are providers for Iowa Children's Dental Medicaid Plans for IME, Delta Dental, and hawki for children. WE ARE NOT PROVIDERS for MCNA in Iowa or Nebraska.
Is this patient covered by any of the following Iowa Medicaid Dental Plans?
*
YES - Iowa DWP with Delta Dental
Yes - Iowa IME
Yes - Iowa hawki with Delta Dental
NO - This patient is not enrolled in any of the Iowa Medicaid Plans listed above
Please Call If you Have any questions or problems submitting this form. Thank You! 712-276-2766
Printing Options:
Please "Preview PDF" to view and print a copy for Patient/Parent
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