Registration Form

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Patient Full Name *(Required)

Date of Birth(Required)

Sex(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Cell Phone Number

Referring Doctor

Emergency Contact(Required)

Phone(Required)

Full Time Student

Yes

If yes, name of college

Responsible Party Info/Insurance Subscriber Info: *The family member your insurance is through

Full Name(Required)

Date of Birth(Required)

Relationship to Patient(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Cell Phone Number

Employer

Medical Insurance Carrier

Member ID No.

Group ID No.

Phone No.

Dental Insurance Carrier

Member ID No.

Group ID No.

Phone No.

Signature *(Required)

Date(Required)

OFFICE NOTES - Leave Blank- For Office Use Only

Privacy Practices

My signature below indicates that I have been given the chance to review a current copy of my doctor’s “Notice of Privacy Practices.” My signature means that I agree to allow my doctor to use and disclose my personal information to carry out treatment, payment, and other necessary healthcare operations.

Signature *

Date

Fees and Payment

I understand and agree that all fees are the responsibility of the patient and/or responsible party, due and payable within 90 days from the day of service, irrespective and regardless of any insurance claims or other anticipated benefits. Account balances older than 90 days will be subject to interest charges in the amount of 18% per annum, and further subject to collection fees which would accrue should it become necessary to enlist an outside agency for collection services.

Patient Signature *(Required)

Date(Required)

I hereby authorize payment directly to Oral Facial Surgery Institute, Inc., of benefits due me for services provided by him and/or his representatives. I understand that I am financially responsible for the entire cost of services provided regardless of insurance coverage. I hereby authorize the release of any information acquired in the course of my treatment as may be necessary to process my insurance claim.

Patient Signature *(Required)

Date(Required)

Authorization for Release of Information to Family and/or Friends

Patient Name

Date of Birth

Oral Facial Surgery Institute, Inc. is authorized to release protected health information about the above-named patient to the entities named below.

Medical Information

Results from Tests or X-rays

Financial Information

Family/Friend Name

Phone

Family/Friend Name

Phone

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Registration Form

Please Fill in the Required Information