Liberty Hill Gillespie - Patient Info Update

Patient Information

Please fill in all information.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #
Gender*

MaleFemale
Employer:
Occupation:
Marital Status:*

SingleMarriedDivorcedOther
Primary Care Information
Primary Care Physician (First, Last Name & Specialty, OR Practice Name)
Date of Most Recent Physical Exam

MonthDayYear
Date
Purpose of Most Recent Physical Exam
What is the condition of your health?*

ExcellentGoodFairPoor
Insurance Information

Please fill in all information as complete as possible. If you have a card you can upload an image of it. If you do NOT have an insurance card, a social security number will be required to verify benefits prior to your appointment.
Do you have Dental Insurance?*

YesNo
Insurance Company
Insurance Phone Number
Please enter a valid phone number.
Claims Mailing Address
Subscriber Name & Relation to Patient
Subscriber Date of Birth

MonthDayYear
Date
Subscriber ID#
Group# / Employer
Please upload an image of the front AND back of your insurance card.

If you are unable to upload an image of your insurance card, please be ready to provide your card to our front office staff at check-in.
Cancelof
Medical History UPDATE

Please complete the following information pertaining to your medical history.
In the last 12-24 months, have you been hospitalized for illness or injury?*

YesNo
If yes, please explain.
Have you had an allergic reaction to any of the following?*

Aspirin, Ibuprofen, AcetaminophenPenicilinErythromycinTetracyclineFluorideMetals (gold, stainless steel)LatexCodeineSulfaAny Other MedicationsNone of the Above
If yes, please indicate reaction:

Do you have or have you ever had any of the following conditions, diseases or illnesses?*

	Yes	No
Heart Problems
Heart Murmur
Rheumatic Fever
Scarlet Fever
High blood pressure
Low blood pressure
A stroke
Artificial Prosthesis (i.e. a heart valve, joints)
Anemia or other blood disorder
Prolonged bleeding due to a slight cut
Emphysema
Tuberculosis
Asthma
Breathing/sleeping habits (i.e. snoring, sinus)
Used CPAP or appliance
Often exhausted or fatigued
Kidney disease
Liver disease
Jaundice
Thyroid or parathyroid disease
Hormone deficiency
High cholesterol
Diabetes
Stomach or duodenal ulcer
Digestive disorders (gastric reflux)
Osteoporosis/osteopenia (taking bisphosphonates)
Arthritis
Glaucoma
Contact lenses
Head or neck injuries
Epilepsy/convulsions (seizures)
Neurological problems
Viral infections and cold sores
Any lumps or swelling in the mouth
Hives, skin rash, hay fever
Venereal disease
Hepatitis
HIV/AIDS
Tumor, abnormal growth
Radiation therapy
Chemotherapy
Emotional Problems
Often unhappy or depressed
Psychiatric treatment
Antidepressant medication
Alcohol/drug dependency

If you answered yes to any of the above questions, please explain:

Are you currently:*

	Yes	No
Being treated for any other illness?
Aware of change in your general health?
Taking meds for weight management?
Taking dietary supplements?
Subject to frequent headaches?
A smoker or smoked previously?

Are you taking birth control?

YesNo
Are you pregnant?

YesNo
Are you suffering from a prostate disorder?

YesNo
If you answered yes to any of the above questions, please explain:
List all CURRENT medications, supplements and vitamins you are taking. After your final entry, you must click "save and add row" to finish. If you are NOT taking any medications, please type "none" and then click "save and add row". *
Appointment Confirmation
Our goal is to provide quality dental care that you have come to know and trust to all our patients. No-shows, late arrivals, and cancellations make it more difficult to see our patients in a timely manner. As a courtesy, your appointments can be confirmed electronically the week before your scheduled appointment by email and/or text messaging from our online appointment scheduling software because we know how easy it is to forget an appointment you booked months ago.

From this confirmation email and/or text, you have the option of the following:

• Confirm your appointment from the link provided in the email;

• Confirm your appointment by simply responding with the letter “C” in the confirmation text;

• Cancel your appointment with a response to do so;

• Respond back from your confirmation email and/or text with any changes or issues;

• Call the office at 512-515-0171 to reschedule your appointment;

• Call the office at 512-515-0171 and leave a message if it goes to voice mail;

We appreciate the fact that you have chosen Liberty Hill Dental to provide for your dental needs and always want to respect your time. We always strive to get our patients that are in pain or having a dental emergency in that same day. Please call Liberty Hill Dental as soon as you know you will not be able to make your appointment. When possible, please call at least 24 - 48 hours in advance. Appointments are in high demand, and your advanced notice will allow another patient access to that appointment time.

We appreciate your support and understanding!
Signature*

Clear
Date*

MonthDayYear
Date
___________________________________________

Doctor's Signature
Please do NOT close this window or navigate away until you see confirmation that the submission has completed.

Upon successful submission of your paperwork, you will receive an email notification that your form has been successfully submitted. If you do not receive the confirmation email, please check your spam folder or call our office prior to your appointment to confirm that your paperwork has been submitted and received successfully.
Should be Empty:

Patient Information

Primary Care Information

Insurance Information

Medical History UPDATE

Appointment Confirmation