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2025 Patient Registration

Patient Information

Name(Required)
MM slash DD slash YYYY
Residential Address
Gender

Contact Information of the Patient

Responsible Party's Information

Address

Emergency Contact Information

Primary Dental Insurance Details

MM slash DD slash YYYY
Electronic signature (ESign) & Date
Clear Signature

Secondary Insurance Information

MM slash DD slash YYYY

Disclaimer

I authorize the release of all medical information to my insurance company, physician or dentist as deemed necessary in the professional judgment of my oral surgeon. I assign all insurance benefits which I am entitled, to OM3 Surgery. This assignment shall remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I understand as the responsible party I am financially responsible for all charges, regardless of any insurance coverage, Including all lab fees for surgical guides and temporary crowns, flippers or dentures. I understand and agree that if the bill is not paid in full within 30 days of the services provided, I will be charged interest at the rate of 12% per annum, compounded monthly on any balance due.

I HAVE COMPLETED AND READ THE INFORMATION ABOVE AND UNDERSTAND IT.

Cancellation Policy:
I understand that if I no-show or cancel my surgical appointment without at least 48 hours notice during business hours (Monday-Friday), I will be charged a non-refundable $125 cancellation fee and must pay 50% of my patient portion to reschedule my surgery. Voicemails and text messages left after business hours are not accepted as valid cancellations.

I HAVE COMPLETED AND READ THE INFORMATION ABOVE AND UNDERSTAND IT.
Patient/Responsible Party (ESign) & Date
Clear Signature
MM slash DD slash YYYY
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