• Patient Update Form - McKinneyDentist.Com

    In our best efforts to take the best care of our patients, we ask that our patients update their information annually. Please complete this form in its entirety to ensure the accuracy of your file. Thank you!

  • Personal Information

    Please enter your personal details below.
  • Todays Date*
     - -
  • Patients Date of Birth*
     - -
  • 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.*
  • Format: (000) 000-0000.
  • COMMUNICATION BY TEXT MESSAGE (including appointment reminders). Do you wish to receive communication by text message? If Yes, I authorize communication by text which may include appointment reminders, healthcare operations, marketing, or other purposes. I understand I may OPT OUT or customize my correspondence at any time.*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance

  • 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)

  • Policy Holder Date of Birth
     - -
  • Are you the:*
  • Format: (000) 000-0000.

  • Medical History

  • Are you under a physician's care now?*
  • Are you taking a blood thinner? Ex:Coumadin*
  • WOMEN: are you nursing, pregnant or trying to get pregnant?
  • Are you allergic to any medications?*
  • Are you allergic to latex?*
  • Do you require medication prior to a dental appointment?

  • Medical Information

  • Check All That Apply*

  • Submission

  • Appointment Confirmation Policy & Consent Form
    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

  • Yes, 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.*

  • Consent to Submit form


    I understand that I am submitting this information in it's entirety to McKinney Dentist.Com. We will always ensure your privacy and protection. Thanks for taking the time to do this. We look forward to seeing you! ~ McKinneyDentist.Com*

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