Patient Information | Form 300

Welcome to Lxuoral patient portal page! We are thrilled to have you as a new patient and committed to continuously serving our existing patients. At luxoral we believe in delivering the highest standard of care possible. To ensure a better and pleasant experience with Luxoral, we kindly ask you to fill out all the required forms, including our new patient information form, health history form, dental history form, HIPAA consent form, and privacy of practice form. Thank you for choosing Luxoral, and we look forward to seeing you soon!

Patient Information | Form 300

Personal Information

First Name

Last Name

Gender

Male

Female

Other

Birthday

Driver License or State ID #

Social Security

Phone

Cell Phone

Home Address

Choose your County

City

State

Zip Code

Parent's or Guardian's Name

Relationship to Patient

Emergency Contact Name

Relationship

Phone

Employer Information

Occupation

Employer

Work Phone

Employer Address

City

State

Zip Code

Financial Responsibility

Do you have dental insurance?

Yes

Name of Insurance Plan

Subscription ID Number

Group #

Method of Payment

How did you hear about us?

By checking this box and signing below, I hereby declare that the above made statements are true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury.

Date Signed

Patient or Parent/Guardian Signature

Please enter your invitation or promotion code below if applicable:

For a faster process, please upload a picture of your driver license or state ID, along with your dental insurance card if applicable: