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Patient Information

Patient Forms 

New Patient Forms

If you are ready to schedule an appointment with our dentists at any of our Austin or Round Rock locations, you have the option of completing our new patient form online to save you time on your first visit. Click on the link below to access the PDF form. You can print the form to fill out by hand or save to your computer to fill in the fields and then print the form to add your signature. Once completed you may scan the form to email/fax to the Rose Dental location you will be visiting or bring the printed form with you to your dental appointment. If you have any problems with the form feel free to call our office and we will gladly assist you. Please visit our Contact Us page to see the email addresses and fax lines associated with each location.

New Patient Paperwork 5 Pages

Please read the below attachments, as you will be asked to sign an acknowledgement of receipt at your appointment.

Patient Policies 2 Pages

Notice of Privacy Practices

Existing Patient Forms

For your convenience we have have added our existing patient forms below. Click on the link below to access the PDF form. You can print the form to fill out by hand or save to your computer to fill in the fields and then print the form to add your signature. Once completed you may scan the form to email/fax to the Rose Dental location you will be visiting or bring the printed form with you to your dental appointment. If you have any problems with the form feel free to call our office and we will gladly assist you. Please visit our Contact Us page to see the email addresses and fax lines associated with each location.

Medical History - Existing patients will complete this forms to update their Medical History for their annual exam and cleaning.

Parent-Guardian Consent for Treatment of Unaccompanied Minor - Parents or Guardians may print and fill out the above form to send with a minor that will be coming alone or when a minor is brought in by someone that is not the legal guardian. The Parent or Guardian may also fax or email the form before the minor arrives.

Authorization for Release of Dental Records - Patients requesting records be sent to a different office need to fill out the above form. The form may be emailed, faxed or brought into the office.

Specialist Referral Forms

Provider use only - Click on the link below to access the PDF form. You will print the form to fill out by hand. Once completed you may email/fax the forms to the Rose Dental location that the patient will be visiting. If you have any problems with the form feel free to call our office and we will gladly assist you. Please visit our Contact Us page to see the email addresses and fax lines associated with each location.

Oral Surgery Referral Form - This form is to be used by referring doctors to Rose Dental's Oral Surgeons.

Orthodontic Referral Form - This form is to be used by referring doctors to Rose Dental's Orthodontists.

This web site uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.


Payment Options 

We accept most insurance plans and are happy to file on your behalf.  However please make note that your insurance is an agreement between you and your insurance company.  For any services not covered by insurance your payment is due at the time of service.

For the convenience of our patients we are glad to offer a variety of payment options.  Our office accepts cash, personal checks and all major credit cards including CareCredit. 

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At this time our Billing Department accepts payments by phone or mail with the exception of CareCredit. CareCredit payments can be made in person at our offices. We will have online bill pay added soon.


Financing with Care Credit

We’re pleased to offer our patients the CareCredit® card, North America's leading patient payment program. 

CareCredit lets you begin your treatment immediately — then pay for it over time with low monthly payments that fit easily into your monthly budget. Now you don’t have to save up for years to finally get the smile you’ve always wanted. 

CareCredit is the credit card exclusively for healthcare services. CareCredit offers low monthly payment plans for healthcare procedures not commonly covered by insurance, including dental treatments. Plus, you can use your CareCredit card over and over for follow-up appointments.

Learn more by visiting CareCredit.com or contacting our office. Ready to apply? Apply online for your CareCredit card today.




You may request an appointment online, via live chat, by calling us, or by email.

We have four convenient locations to serve you!

11615 Angus Rd., #110, Austin, TX 78759
P: 512-795-9643 • F: 512-795-9959

6211 W. William Cannon Dr., Austin, TX 78749
P: 512-288-4447 • F: 512-288-4774

893 N. IH-35, #200, Round Rock, TX 78664
P: 512-310-9374 • F: 512-244-3954

1450 W. Parmer Ln., Austin, TX 78727
P: 512-251-6125 • F: 512-251-6126

   

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