McKinneyDentist.Com New Patient Forms

McKinneyDentist.Com New Patient Forms

Please send this form prior to your first appointment with us.
Personal Info

Please enter your personal details below.
What to Expect
Your first appointment with McKinneyDentist.Com could be the first step to life lasting dental health.

Arriving for your first appointment, we will:

*Greet you and Welcome you.
*Take you on a tour of our office and offer you a beverage
*Take digital photographs and radiographs
*Perform a thorough examination
*Discuss your wants and treatment options
*Provide you with an overview of costs and timelines

We would LOVE to give you the best possible dental care, but to do that we need to know more about you. Please begin listing detailed information about your current health, habits, and requirements for medication(s). This will provide us with clarity which avoids misinterpretation.

You may choose to fill these forms out now (recommended) or at our office.

YOUR PRIVACY: This form is completely secure. The form here is embedded in the McKinneyDentist.Com domain for ease of use. You don't see the "s" after http: because it's embedded.

McKinneyDentist.Com enforces the secure collection of data. Forms will be served across a protected, 128-bit SSL connection that encrypts the data before it is sent to our servers. SSL ensures that any wrong-doer who may be "listening" to internet traffic is not able to actually read the data being submitted to the form. McKinneyDentist.Com is the only one to ever be able to access the information.

Our SSL encryption is done on EACH form and transmits the data securely, and we're confident it will remain secure on our servers. However, some data is so sensitive we wanted even stricter encryption in place. We have a redundant level of encryption takes place on certain private fields in this form. This means that sensitive data such as name and SSN will not be compromised even if our physical server is EVER compromised. Just like our dental care, our security and privacy are top-notch!

We looking forward to meeting you !
~McKinneyDentist.Com Team
Full Name

First NameLast Name
Name You Would Like To Go By?
Patient Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
SSN Social Security Number
COMMUNICATION BY EMAIL(including appointment reminders). Do you wish to receive email communication? If Yes, I authorize communication by email which may include appointment reminders, healthcare operations, marketing, or other purposes. I understand I may OPT OUT or customize my correspondence at any time.
Email Address
example@example.com
COMMUNICATION BY TEXT (including appointment reminders). Do you wish to receive communication via text message? If Yes, I authorize communication by text message which may include appointment reminders, healthcare operations, marketing, or other purposes. I understand I may OPT OUT or customize my correspondence at any time.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party's Name
Name of Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How Did You Find Us?
If someone referred you, whom may we thank?
Agreement
I hereby authorize McKinneyDentist.Com doctors and team members to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate to make a thorough diagnosis of my (or my dependent's) dental needs. Upon such diagnosis of my dental needs, I authorize McKinneyDentist.Com to perform all recommended treatment that is mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service and any insurance claims will be filed and reimbursed to me directly.
I accept McKinney Dentist.Coms' Agreement (above)
Our Commitment to You
At McKinneyDentist.com, we strive to provide the highest level of care to all our patients. In order to serve everyone efficiently, we require appointment confirmations to secure your scheduled time.
Confirmation Policy
• Patients will receive multiple reminders via text, email, or phone leading up to their appointment.
• All appointments must be confirmed at least 48 hrs prior to appointment.
• Unconfirmed appointments are subject to cancellation and may be given to another patient.
• No-Shows & Cancellations within 24 hrs of appointment time will result in a $50 rebooking fee.
How to Confirm Your Appointment
• Reply YES to text or email confirmations.
• Call our office at 972-547-6453 to confirm or reschedule.

Acknowledgment & Agreement
I understand and agree to the appointment confirmation policy outlined above. I acknowledge that if I do not confirm my appointment at least 48 hrs in advance, my appointment may be canceled and given to another patient.
I accept McKinney Dentist.Coms' Confirmation Policy (above)

Employer & Insurance
Primary Dental Insurance- (Note: Patients with Delta Dental Insurance will pay in full at the time of service & as a courtesy a claim will be filed on your behalf. Any Insurance Reimbursement will be issued to the Subscriber)
Is the patient the:
Primary Dental Insurance Company
Policy Holders Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Subscriber ID #
Group #
Name Of Employer:
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Submission
We are excited to meet you. Please let us know if there's anything we can do to make your visit as pleasant as possible. Also if there's any information that you feel would be pertinent that we may not have asked about, please list it here. Again, we look forward to meeting you!
Should be Empty:

McKinneyDentist.Com New Patient Forms

Personal Info

Employer & Insurance

Medical & Dental History

Medical Info

Submission