Online Patient Registration
You may preregister with our office by taking our online patient interview. You will be presented with an interactive question and answer presentation that facilitates form completion. This narrated interview system enables a more accurate form completion process. This presentation will save you time! It eliminates the need for you to fill out traditional health care forms in our office.
When you are ready to begin, click the "Online Registration Form" button below. A simple question and answer process will commence. After you have completed the interview, the patient information collected is securely encrypted and sent to our office.
On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.
[Click to Expand, All Documents PDF Format & Require Adobe Acrobat Reader]
Pre-Operative Instructions | Post-Operative Instructions | Directions / Appointment Confirmation | Patient Registration Form
Fees and Payments
We make every effort to keep down the cost of your oral surgical care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you. If you have any dental and/or medical insurance, we'll be glad to fill out the proper forms, but please complete the identifying information at the top of the form.
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, coinsurance or any other balance not paid for by your insurance company.
This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment directly to the dentist named of the insurance benefits otherwise payable to me.
Signature ________________________________________________
Date ____________________________________________________
Health
History
To
Our Patients:Although
oral surgeons primarily treat in the area in and around
your mouth, your mouth is a part of your entire body. Health
problems that you may have or medication that you may be
taking could have an important interrelationship with the
care that you will be receiving. Thank you for answering
the following questions: Your answers are for our records
only and will be considered confidential women's
Note: Antibiotics (such
as penicillin, erythromycin, etc.) and some pain medications
may alter the effectiveness of birth control pills. Consult
your physician/gynecologist for assistance regarding additional
methods of birth control. I
certify that I have read and understand the above. I acknowledge
that my questions, if any, about the inquiries set forth
above have been answered to my satisfaction. I will not
hold my surgeon, or any other member of his staff, responsible
for any errors or omissions that I may have made in the
completion of this form.
Signature
of Patient: ___________________________________________
Reviewed
By: ________________________________________________
|
