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Cornerstone Dental
Phone 703-771-3389
Cornerstone Dental

Testing

New Patient Information Form

1Patient Information
2Insurance Information
3Phone Numbers
4Dental History
5Health History
6Medications, Supplements, Remedies & Allergies
7Physicians
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Assignment and Release

    I Certify that I, and/or my dependent(s), have insurance coverage with the following Insurance Company(ies) and assign directly to Cornerstone Dental all insurance benefits, of any, otherwise payable to me for services rendered. I Understand that I am financially responsible for all charges whetehr or not paid by insurance. I authorize the use of my signature on all insurance submissions.

  • I give my permission to Cornorstone Dental and its affiliates to use and disclose my health care information to the Insurance Company (ies) I so designate and their agents for the purpose of determining insurance benfits, obtaining payment for services, or the benefits payable for related services.
  • MM slash DD slash YYYY
  • In case of emergency, Contact

    (Specify someone who does not live in your household)

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Place a mark on 'Yes' or "No' to indicate if you had any of the following:

  • MM slash DD slash YYYY
  • Place a mark on 'Yes' or "No' to indicate if you had any of the following:

  • Women

  • MM slash DD slash YYYY
  • Allergies

  • Please list names, location and phone numbers of all your attending doctors.

    • We invite you to discuss with us any questions regarding our services. The best dental health services are based on a friendly mutual understanding between provider and patient.
    • Our policy requires payment in full at the time services are rendered, unless other formal written arrangements have been made with our office management. If the account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for all legal fees, collection agency fees, interest charges and any other expenses incurred for collection of the debt.
    • I authorize the staff of Cornerstone Dental to perform any necessary services needed during diagnosis and treatment.
    • Filing of insurance claims is a courtesy we provide to our patients. I authorize Cornerstone Dental to release any information required to process my insurance claims.
    • I understand the above information and state this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to this information I provided.
  • MM slash DD slash YYYY

© 2025 Cornerstone Dental | Website by SentryPress

  • Home
  • Dr. Moon
  • Dr. Chiu
  • Our Practice
    • Reviews
  • Procedures
    • Invisalign
    • Cleanings & Prevention
      • Dental Exams & Cleanings
      • Dental X-Rays
      • Digital X-Rays
      • Fluoride Treatment
      • Home Care
      • How to Properly Brush & Floss
      • Oral Cancer Exam
      • Oral Hygiene Aids
      • Panoramic X-rays
      • Sealants
    • Cosmetic Dentistry
      • Composite Fillings
      • daVinci™ Veneers
      • Day White®
      • Dental Implants
      • Empress® Restorations
      • Porcelain Crowns (Caps)
      • Porcelain Fixed Bridges
      • Porcelain Inlays
      • Porcelain Onlays
      • Porcelain Veneers
      • Procera® Crowns
    • Periodontal Disease
      • What is Periodontal (Gum) Disease?
      • Diagnosis
      • Treatment
      • Maintenance
      • Causes of Periodontal Disease
      • Types of Periodontal Disease
      • Signs & Symptoms of Periodontal Disease
      • Mouth – Body Connection
      • Periodontal Disease and Diabetes
      • Periodontal Disease, Heart Disease and Stroke
      • Periodontal Disease and Pregnancy
      • Periodontal Disease and Osteoporosis
      • Periodontal Disease and Respiratory Disease
    • Restorations
      • 3i Dental Implants
      • Composite Fillings
      • Crowns (Caps)
      • Dental Implants
      • Dentures & Partial Dentures
      • Empress® Restorations
      • Fixed Bridges
      • Inlay Restorations
      • Onlay Restorations
      • Root Canal Therapy
    • Orthodontics
      • What is Orthodontics?
      • What is an Orthodontist?
      • What is a Malocclusion?
      • Who Can Benefit From Orthodontics?
      • Orthodontic Treatment Phases
      • Do Braces Hurt?
      • Care Following Orthodontics – Retainers
      • Invisalign®
      • Why Straighten Teeth?
      • Orthodontic Dictionary
    • Oral & Maxillofacial Surgery
      • Dental Implants
      • 3i Dental Implants
      • Mini Dental Implants
      • Oral Pathology
      • Sleep Apnea
      • Sleep Apnea Appliances
    • Periodontics
      • What is a Periodontist?
      • When to See a Periodontist
      • Antibiotic Treatment
      • Bone Grafting
      • Bruxism
      • Crown Lengthening
      • Gum Grafting
      • Gum Recession
      • Oral Cancer Exam
      • Periodontal Scaling & Root Planing
      • Pocket Irrigation
      • Pocket Reduction Surgery
      • Prophylaxis (Teeth Cleaning)
      • Regenerative Procedures
      • Soft Tissue Grafting
    • Endodontics
      • Cracked Tooth
      • Root Amputation
      • Root Canal Therapy
    • Dental Emergencies
    • Prosthodontics
      • Crowns (Caps)
      • Dental Implants
      • Dentures & Partial Dentures
      • Fixed Bridges
      • Porcelain Veneers
    • Pediatric Dentistry
      • Baby Bottle Tooth Decay
      • Care for Your Child’s Teeth
      • Dental Emergencies
      • Dental Radiographs (X-Rays)
      • Does Your Child Grind His or Her Teeth at Night?
      • Early Orthodontic Treatment
      • Eruption of Your Child’s Teeth
      • Fluoride
      • First Visit
      • Good Diet
      • How Often Should Children Have Dental Checkups?
      • How to Prevent Cavities
      • Mouth Guards
      • Pacifiers and Thumb Sucking
      • Pediatric Dental Appliances
      • Perinatal and Infant Oral Health
      • Sealing Out Tooth Decay
      • Sedation Dentistry for Children
      • Sippy Cups
      • Tobacco Use
      • Tongue Piercing
      • What is Pulp Therapy?
      • What’s the Best Toothpaste for My Child?
      • When Should Children Have Their First Dental Visit?
      • When Will My Baby Start Getting Teeth?
      • Why Are Primary Teeth Important?
      • Why See a Pediatric Dentist?
      • Xylitol – Reducing Cavities
    • Surgical Instructions
      • After Dental Implant Surgery
      • After Tooth Extractions
      • Before General Anesthesia
  • Smile Analysis
  • Faqs
    • Links
  • Contact Us