• Patient Information

    Please fill in all information.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Social Security Number
  • Gender:*
  • Marital Status:*
  • Format: (000) 000-0000.

  • Person Responsible for Account

    Responsible party MAY be different than the Primary on your insurance account. Please fill in all information.
  • Is the Patient ALSO the Person Responsible for Account?*
  • Relation to Patient:*
  • Social Security Number
  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender:*
  • Marital Status:*

  • 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?*
  • Format: (000) 000-0000.
  • Subscriber Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Additional Information

  • APPOINTMENT REMINDERS

    We understand your time is very important. We also know that life can get a little crazy. Sometimes, your appointment will be scheduled as far as 6 months out. Because of this, we want to make sure to remind you of your appointment and do so over the span of a few months leading up to your scheduled date.

    We use a reminder system that will notify you by email, text and phone call from the time your appointment is scheduled until 2 hours prior to your appointment. This system gives you the option to confirm your appointment through email, then through text with a friendly reminder 2 hours prior to your appointment. Once you have confirmed your appointment (either through the emailed link or by texting back “C” to confirm), you will only receive reminders.

    Note: If any other phrase is used to confirm (ie. “Yes”, “OK” or “See you then”, “Need to Reschedule”, etc.) the system will not recognize that response. You must press “C” to confirm, or “STOP” to completely opt out of the reminder notification process.

    In the event that you respond with the phrase “STOP”, be aware this will completely opt you out of any reminder notifications for all future appointments until you inform us to turn it back on.

    If you need to cancel or reschedule your appointment, please call the office.

    Please make sure your information is correct and update our staff with any contact information changes, such as address, email or phone number changes to ensure you receive your reminders.

    Thank you for allowing Liberty Hill Dental to provide your dental care.

  • Initials*
  • How did you hear or find Liberty Hill Dental?*
  • Today's Date:
     - -
    2 digit month, 2 digit day, 4 digit year
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