Robert D. White, DDS

Robert D. White, DDS

140 Joe Wimberley Blvd/P.O. Box 319, Wimberley, Texas 78676

Phone: 512-847-9521 Fax: 512-847-6185

Patient’s Name:Click here to enter text. Preferred Name: Click here to enter text.

Spouse Name (if married):Click here to enter text. Parent’s Name (if a child)Click here to enter text.

Date of Birth: Click here to enter text. SSN: Click here to enter text. Driver’s License# Click here to enter text.

Home Address: Click here to enter text. City, State, Zip Click here to enter text.

Billing Address (if different from home):Click here to enter text.

Telephone Numbers: Home: Click here to enter text. Work: Click here to enter text. Cell: Click here to enter text. Email Address: Click here to enter text.

How do you prefer to be contacted? ☐by phone and/or mail ☐by email and/or text

Previous Dentist: Click here to enter text. Phone Number: Click here to enter text.

Current Physician: Click here to enter text. Phone Number: Click here to enter text.

Do you have dental insurance? ☐Yes ☐No

☐Individual Policy or ☐Employer Provided; Employer: Click here to enter text.

Dental Insurance Carrier: Click here to enter text. Group Number: Click here to enter text. ID Number: Click here to enter text.

Name of Policy Holder: Click here to enter text. Relationship to patient: Click here to enter text.

Policy Holders: Date of Birth: Click here to enter text. SSN (for insurance ID): Click here to enter text.

Please remember that insurance is considered a method of reimbursement for fees paid to the dentist and is not considered a substitute for payment. We will be happy to assist you in preparing your insurance claims and to answer any questions you may have. Dr. White is not a contracted “in-network” provider with any insurance plans. If your plan provides out-of-network coverage (PPO) any claims for services rendered to you by our office will be paid on an out-of-network fee schedule, determined by your insurance plan and subject to adjustment by the insurance plan’s allowable fees. Any balances remaining after insurance has made payment on a claim are the responsibility of the patient or parent/guardian.

Please be aware that delinquent accounts of more than 60 days will be referred to IC Systems, a nationwide collection company, for payment. Delinquent accounts will be charged an annual rate of interest at 18% (monthly rate of 1.5%) on the unpaid balance. Collection fees will be added to all delinquent accounts referred.

Electronic Signature: Click here to enter text. Date: Click here to enter a date.