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documents/medical/oral_surgery/201610181224191000.md

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+---
+type: medical
+category: oral surgery
+person: Xuewei Jiang
+date: 2016-10-10
+provider: Midtown Oral & Maxillofacial Surgery
+source: 201610181224191000.jpg
+---
+
+# Midtown Oral & Maxillofacial Surgery
+
+**H. Paul Casmedes, D.D.S., M.D. / Ann H Kristovich, D.D.S.**
+Suite 410
+Board Certified, American Board of Oral & Maxillofacial Surgery
+
+901 West 38th Street,
+Austin, TX 78705
+
+---
+
+**Patient Type:** New Patient
+
+**Pediatrician / Primary Care Doctor:**
+**Referring Physician:** Dr. Mary Becher
+
+**Date:** 10/10/2016
+
+---
+
+## PATIENT INFORMATION
+
+| Field | Value |
+|---|---|
+| Patient's Last Name | Jiang |
+| First | Xuewei |
+| Middle | |
+| Age | 23 |
+| Sex | Female |
+| Date of Birth | 03/13/1993 |
+| Street Address | 1652 W 6st Apt R |
+| Social Security No. | 092-99-3215 |
+| Primary Phone Number | (254) 214-1350 |
+| City | Austin |
+| State | TX |
+| ZIP Code | 78703 |
+| Secondary Phone Number | (254) 224-1457 |
+
+### Ethnicity
+
+- [ ] Hispanic or Latin
+- [x] Not Hispanic or Latin
+- [ ] Refuse to Report
+
+### Race
+
+- [ ] American Indian or Alaska Native
+- [x] Asian
+- [ ] Native Hawaiian
+- [ ] Black or African American
+- [ ] White
+- [ ] Hispanic
+- [ ] Other Race
+- [ ] Other Pacific Islander
+
+| Field | Value |
+|---|---|
+| Primary Parent / Guardian Name | |
+| Email | |
+| Social Security No. | |
+| Daytime Phone | |
+| Date of Birth | |
+| Employer | |
+| Employer phone No. | |
+| Second Parent / Guardian Name | |
+| Marital Status of Parents | Married |
+
+### Emergency Contact
+
+| Field | Value |
+|---|---|
+| In case of emergency, please contact | Yanxin Lu |
+| Phone Number | (254) 224-1457 |
+| Relation | Spouse |
+
+---
+
+## INSURANCE INFORMATION
+
+### Primary Insurance
+
+| Field | Value |
+|---|---|
+| Type | Dental |
+| Name of Primary Insurance | Delta Dental |
+| Subscriber's Name | Xuewei Jiang |
+| Subscriber's S.S. # | 092-99-3215 |
+| Subscriber's Date of Birth | 03/13/1993 |
+| Subscriber's Sex | Female |
+| Policy No. | V17NK34D |
+| Group No. | 5968 |
+| Group Name | |
+| Subscriber Address | |
+| Patient's relationship to subscriber | Self |
+| City | Austin |
+| State | TX |
+| ZIP Code | 78703 |
+
+### Secondary Insurance
+
+| Field | Value |
+|---|---|
+| Name of Secondary Insurance | Blue Cross Blue Shield |
+| Subscriber's Name | Xuewei Jiang |
+| Subscriber's S.S. # | 092-99-3215 |
+| Subscriber's Date of Birth | 03/13/1993 |
+| Policy No. | V17NK34D |
+| Group No. | 071778 |
+| Group Name | |
+| Subscriber Address | |
+| Patient's relationship to subscriber | Self |
+
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