Patient Registration


Instructions

  1. Complete the secure online registration form below.       En Español
    - or -
  2. Download, print and complete the PDF registration form. Download Spanish form.

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Patient Registration

Party Responsible for Payment

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Primary Medical Insurance

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Add Secondary Medical Insurance

Secondary Medical Insurance

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Primary Dental Insurance

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Add Secondary Dental Insurance

Secondary Dental Insurance

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Upload Files

Scan and Upload the front and back of your medical and dental insurance cards. Maximum of four files.

Selected Files:

People To Contact If Needed

Medical History

What brings you to our office?
Have you been a patient in a hospital in the past 5 years?
Have you been under the care of a physician during the past 5 years?
Have you ever taken any kind of medication to increase bone density or prevent bone destruction for osteoporosis or cancer?
List all medications (including herbal remedies) taken during the past year.
What kind of reaction did you have to the medications?
Have you ever had any excessive bleeding requiring special treatment?
Select any of the following which you have had:
Have you ever had any other serious illness?
Have you been diagnosed with any immune disorder? (Radiation treatment, Chemotherapy, Splenectomy, Steroid use)
Have you ever had any problems with your temporomandibular joints (jaw joints); e.g., noises, pain, or limited opening?
Have you or anyone in your family had any problems with general anesthesia?
Has a member of your family been seen in our office before?
Are you wearing contact lenses?

Acknowledgement of Anesthesia and Medication use in your Care

I acknowledge that certain medications that may be prescribed to me by my doctor at The Center for Oral & Maxillofacial Surgery, s.c. may alter my state of mental awareness and decision making. Depending on the type of anesthetic given, I understand the importance of adhering to the following:

  • Refrain from driving a car.
  • Refrain from operating machinery of any kind.
  • Refrain from making important personal or business decisions.
  • Refrain from drinking alcohol of any kind.
  • Refrain from taking sedatives (prescribed by another doctor or over-the-counter).

Patient Financial Policy

Payment is expected at the time of service for any office procedure, including consultation and x-rays. For patients covered by a Medical/Dental insurance plan, we will assist you in filing your insurance forms. Most insurance companies will respond within four to six weeks. Please note that insurance rarely pays the entire treatment balance, even if your policy states “100% coverage”. All account balances are ultimately the responsibility of the patient or guardian. Patient, parent or guardian signature is required before treatment begins.

The experienced staff is here to assist our patients. We make every effort to provide you with the finest care, and the most convenient financial options. To accomplish this, we work hand-in-hand with you to maximize your insurance reimbursement for covered procedures.

If your account has a remaining balance it may be paid by cash, check, debit card, Visa, MasterCard, Discover, American Express, or CareCredit. You will receive a statement from our office, which is payable upon receipt. Overdue accounts will be sent to an independent collection agency and/or small claims court.

Any separated or divorced parent accompanying a dependent child for treatment will be considered to be the financially responsible guarantor.

I understand the payment policy and have read it in its entirety. I hereby authorize the release for pertinent medical information necessary for my treatment. I verify that the information I have provided is accurate.

Please remember, you are fully responsible for all fees charged by this office regardless of your insurance coverage.

Request to Access and Disclose Protected Health Information

The Health Insurance Portability and Accountability Act of 1996 establishes an individual’s right to access and receive copies of their Protected Health Information (PHI). Additionally, this act provides for an individual to designate person(s) they are associated with, such as parent, guardian, spouse, child, etc. (this is in addition to their personal physician or dentist) to have access to their PHI. This allows an individual to designate the name(s) or person(s) with whom this confidential information may be shared.

Please enter the name of designated person(s) & relationship below:

Cerification Statement

My signature below indicates that I have read, understand and acknowledge the three policies. I acknowledge that a copy of the privacy policies for The Center for Oral and Maxillofacial Surgery, s.c. were given/offered to me. I certify that the above information is true to the best of my knowledge. I hereby authorize the Center for Oral Maxillofacial Surgery and Dental Implants to release any information required to process my insurance claim/s for services rendered. I understand that I am ultimately financially responsible for any required payment prior to services rendered and any balance remaining on the account after insurance has processed.

COVID-19 Pandemic – Patient Disclosures

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19, also known as "Coronavirus", pandemic.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that such disclosures may impact treatment decisions.

People with COVID-19 have had a wide range of symptoms reported — ranging from mild symptoms to severe illness. These symptoms may appear 2–14 days after exposure to the virus. It is important that you disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

COVID-19 PANDEMIC DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK

The World Health Organization has characterized the COVID-19 virus, also known as "Coronavirus," as a pandemic. Our practice wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.

COVID-19 is highly contagious and has a long incubation period. You or your healthcare providers may have the virus, not show symptoms and yet still be highly contagious. COVID-19 can result in a life-threatening respiratory disease in some patients. You may be exposed to COVID-19 at any time or in any place. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures can create fine water spray or "aerosols" which may remain in the air for several minutes to hours. These aerosols may contain the COVID-19 virus and may create a risk of COVID-19 exposure. You cannot wear a protective mask over your mouth to reduce exposure during treatment as your healthcare providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

To provide a safe environment for our patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal protection, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.

Patient Acknowledgement

I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID-19 exposure with treatment during the pandemic.

I understand and accept the increased risk of COVID-19 exposure with treatment at this office.

I also acknowledge that I could, or may have, exposure to COVID-19 from outside this office and unrelated to my visit here.

I have read and understand the information stated above:

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