lonestarsmiles.org - New Patient Form

New Patient Form

We would like to get to know you better!
Date *

Month Day Year
Name *

First Name Last Name
Date of Birth *

Month Day Year
Gender *
SS#
Address *

Street Address

Street Address Line 2

City State / Province
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone *
Please enter a valid phone number.
E-mail Address *
example@example.com
Occupation
Employer
Parent or Spouse’s Name
Their Phone Number
Please enter a valid phone number.
Who may we thank for referring you?
Emergency Contact
Person name to Contact in case of emergency *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Person responsible for dental investment
For dependents 18 years and older that are covered under parents' insurance, we will need their student status for insurance processing.
Student Status: Full Time Total Semester Hr’s
Part Time Total Semester Hr’s
For Insurance Purposes
Name of policy holder
Date of Birth

Month Day Year
Relationship to Patient
SS#
Member I. D.
Employer
Insurance Company
Ins. Company Phone Number
Please enter a valid phone number.
Group Number
HIPPA Compliance Statement
Your health information may be used in our office to conduct scheduling and coordination of care between the doctor, dental assistant, hygienist, business office staff, and other dental specialists that are involved in your care. We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. Your health information may be reviewed during the routine process of certification, licensing, credentialing activities, or auditing for quality assurance.

Communication with our patients is an important part of our philosophy. We prefer to communicate with you directly but we may incorporate the use of phone messages, postcards, and letters. We will make every effort to respect your privacy and honor your request for confidentiality. If you have special needs in regards to privacy issues, please put them in writing for the office so that we may address your concerns.
Financial Information
I have read and truthfully answered the above questions to the best of my knowledge. I authorize the doctor and/or his staff to release all information necessary to secure payment of my benefits from my insurance company.

I understand that fees may vary at the time of service due to the extent of treatment. Fees are estimates only and are not a guarantee of payment by my insurance company. I understand that the payment of this account is my responsibility, regardless of the amount my insurance company reimburses before or after payment is made.
Patient Signature *

Clear
Patient Name *

First Name Last Name
Date *

Month Day Year

New Patient Form

Emergency Contact

For dependents 18 years and older that are covered under parents' insurance, we will need their student status for insurance processing.

For Insurance Purposes

HIPPA Compliance Statement

Financial Information

Medical History

Women Only

Dental History