(512) 343-2425
Request an appointment!

Patient Questionnaire

    Name:

    Sex:

    Marital Status:

    Address:

    City:

    State:

    ZIP:

    Date of Birth:

    Day

    Month

    Year

    Age:

    Home Phone:

    Cell:

    Email:

    Employer:

    Work Phone:

    Occupation:

    How are you referred?

    Current Physician:

    Previous Dentist:

    Emergency Contact:

    Name:

    Address:

    Phone #:

    Your SSN:

    Person Financially Responsible for Account:

    Name:

    Relationship:

    Address:

    Do you have dental insurance?

    Policy Number:

    Policy Holder:

    SSN:

    Relationship to Patient:

    Place of Employment for Policy Holder:

    Name:

    Address:

    City, State, or Zip:

    Phone:

    Payment for Services:
    Payment for services is required at the time services are rendered, unless other arrangements are made prior to treatment. How will you be paying for your dental treatments? CashCheckCredit CardInsurance

    I assign my insurance benefit to Dr. Taylor and authorize payment for service directly to her.

    OUR POLICY ON INSURANCE
    This office will submit your insurance claims for you, if you direct the insurance company to pay its share of the cost directly to the office (assignment of benefits). At the time of service, we may give you an estimate of amounts we expect your insurance to pay and then may require that you pay your estimated co-pay at that time. Though we state estimates, you are responsible for knowing how your insurance works. Upon receipt of the insurance payment, we will reconcile the account and bill or refund you any difference. You remain responsible for the total cost of dental services, and at any time we may require full payment from you.

    CANCELLATIONS
    We require 24 hour notice when you cancel an appointment, thus allowing this office to give that appointment to another patient. Cancellations with less than 24 hour notice will result in a charge of $35 per hour for the scheduled appointment.

    ADDITIONAL CHARGES
    Charges incurred by Dr. Taylor for NSF checks or to recover unpaid debts will be added to my balance. This includes collection agency fees (ranging from 35% to 50% of the balance due) and attorney’s fees. Interest shall accrue at 18% per annum.

    I HAVE READ AND UNDERSTAND THE TERMS STATED ABOVE.