2025 Patient Registration

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.