Gregory Allen Kerbel, DDS, PLLC
3260 Southern Drive, Suite A
Garland, TX 75043

New Patient Registration for Dr. Greg Kerbel


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Welcome. This form will take about 10 minutes to complete.

Before we begin, you’ll need to gather a few items to make the completion easier: Your SSN and Driver License, Emergency Contact Information, along with Primary and Secondary Insurance details (if needed).

Security

This website is secure and the details you provide will be kept confidential between you and the office of Dr. Greg Kerbel. We consider this information to be very sensitive and it will not be disclosed to any other party without your express written permission.

Questions?

If you have any questions about the security of this form or the handling of your personal information, please contact our office at (972) 278-9901.


Patient Information

Name*
First Name*
Middle Name* (if applicable)
Last Name*
Date of Birth* (MM/DD/YYYY)
Month
Day
Year
Mailing Address
Address Line 1*
Address Line 2
City*
State*
ZIP Code*
Social Security Number*
Marital Status
Contact Information
Email Address*
Confirm Email Address*
Gender*
Home Phone*
Mobile Phone
Work Phone
Employer
Employer
Employer Address Line 1
Employer Address Line 2
City
State
ZIP Code
Employer Phone Number
Occupation
If Student
Name of School/College
School/College City/State/Zip
Driver License

Driver License / State

Who may we thank for referring you?
Doctor:
Patient:
Friend:

GoogleDoctoroogle.comOur WebsiteInternet SearchYelpNew Homeowner Package

Other:

Contact in Case of Emergency
Contact Relationship*
Contact First Name
Contact Last Name
Home Phone*
Cell Phone
Employer Phone

Insurance Information

Primary Dental Insurance
Name of Insured
Relationship to Patient
Date of Birth
SSN or ID Number
Name of Employer
Work Phone
Employer Address Line 1
Employer Address Line 2
City
State
ZIP Code
Union or Local Number

Have you used benefits this year?
YesNo

Insurance Company Name
Insurance Phone Number
Insurance Company Address Line 1
Insurance Company Address Line 2
City
State
ZIP Code
Group Number
Secondary Dental Insurance
Name of Insured
Relationship to Patient
Date of Birth
SSN or ID Number
Name of Employer
Work Phone
Employer Address Line 1
Employer Address Line 2
City
State
ZIP Code
Union or Local Number

Have you used benefits this year?
YesNo

Insurance Company Name
Insurance Phone Number
Insurance Company Address Line 1
Insurance Company Address Line 2
City
State
ZIP Code
Group Number

Patient Health

Do you smoke or use tobacco?

YesNo

Patient Condition (Check all that apply)

If you selected any of the above conditions, or have any other health-related conditions, then please provide additional information.

Have you ever taken Zometa, Aredia, Fosamax, Boniva, Actonel, Skelid, Bonefos, Ostac, Didronel (Bisphosphonate drugs) either orally or by IV?

YesNo
These drugs are used to treat osteoporosis, osteopenia, bone cancer, and post-menopausal bone loss and can cause poor bone healing resulting in osteonecrosis, (death of the bone) which is a very serious and often untreatable complication.

Allergies (Check all that apply)

If you selected any of the above, then please provide additional information.

Weight and Height
What is your current weight in pounds?
Recent weight gain?
YesNo
If "Yes," how much in pounds?
Recent weight loss?
YesNo
If "Yes," how much in pounds?
What is your current height in feet and inches?

Medications
List all medications you are currently taking, include over-the-counter drugs and herbal supplements*
Medication
Dosage
Reason