New PatientsNew PatientStep 1 of 333%Patient NameDOB ** no under 3yrsHow many pt's are we scheduling for?Caller's NameDo you have airway concerns? Yes No$300 for airway consultations or patients under 5 years old.Adult Expansion: Have they met with Dr. Anderson?MK will NOT treat TMJAddressWhat is your BEST number to reach you?What is your preferred method of communication?Call or Text?EmailWho is your/the patient's general dentist?Who may we thank for referring you?What is your/or your dentist's main concern about patient's teeth?Do you have any insurance we may verify on your behalf?Medicaid/Medicare? Yes No** If pt has either, schedule records then phone consult with TC **Insurance CompanyGroup NumberSubscribers NameSubscribers ID/SS NumberSubscribers DOBScheduled Appointment Date/Time:Credit Card NumberExpCVCName on CardDue to appointments being in high demand and an increase in last minute cancellations and no shows we will now be requiring a $50 security deposit to secure and schedule your appointment. We will only process that payment if you no-show or cancel within 24 hours of your appointment time.CommentsThis field is for validation purposes and should be left unchanged.
