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