---
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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