Serving San Antonio, Texas with family dentistry 
and cosmetic dentistry in the Stone Oak area 
Call (210) 495-7800 today 

 

 Dr. Irene Blaess, D.D.S. & Dr. Stan Zebrowski, D.D.S.

cosmetic dentistry  |  spa services  |  appointment request 
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New Patient Information Forms

Save waiting time by registering online

Please fill in this basic personal information, so we can reduce your waiting time during your visit. Questions cover contact, family, insurance, dental and medical information.

*Items marked with an asterisk are required to register online.

Personal Information
*Name:  
Gender:   Marital Status:
 
*Date of Birth:   *S.S.#  
Driver's Lic #
 
*Address: 
City:   State:   Zip:
 
*E-Mail:  
 
Home #   Work #
Cell/Pager #   Employer  
 
Occupation
 
Full time student name of school:  
Grade / Level:
 
How did you hear about us?

Spouse/Parent Information
Name:  
SS#   Date of Birth:
 
Employer:   Occupation:  
Insurance:
 
Address:  
 
Phone #   Relation
Contact in case of emergency: Yes   No

INSURANCE: We will file all necessary forms & reports to your insurance company. We do not render our services on the basis that the insurance company pay our fee. The patient/patient's guardian is personally responsible for any fee the insurance company does not cover.
Person responsible for account:
Relationship to patient:
 
SS#  Date of Birth:
Employer:
 
Primary Insurance:
Group#  Phone#
 
Second Insurance:
Group#  Phone#


 
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