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.

Registration has been submitted, thank you.


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 Acknowledgement of Risk and Health Screening Form

Our practice wants to ensure you are aware of the relative risks of exposure to COVID-19 associated with receiving treatment. This practice has always followed the applicable state and federal regulations and recommendations regarding infection control, sterilization, disinfection, and the use of PPE (personal protective equipment). We also work to protect our patients and office staff from virus spread by promoting frequent hand washing and office cleaning, using PPE for patient encounters, and adding additional environmental controls in the treatment areas.

Although we are using enhanced infection control measures in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing during treatment or for you to wear a mask during treatment. This means that the risk of exposure to COVID-19 remains when receiving treatment during the pandemic.

COVID Health History

Symptoms – Today, or in the last 14 days:

Patient Acknowledgement - By signing this document, I acknowledge that I have read the Patient Acknowledgment and that I understand and accept that there is a risk of COVID-19 exposure with treatment. I also acknowledge that the Health History and Health Screening answers I have provided are true and accurate.

Submit Forms

Once all the above forms have been completed as necessary, please submit them all using this button.

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