Patient Registration

Tell us about the patient, the responsible party, and insurance coverage.

Patient information

Title

First name

Middle initial

Last name

Nickname

Sex

Birth date

Age

Cell phone

Home phone

Email

Social Security number

Street address

City

State

ZIP code

Dentist

Medical doctor

Nearest relative not living with you

Nearest relative phone

Employment status

Student status

Marital status

Person responsible for the account

Responsible party

First name

Last name

Social Security number

Birth date

Age

Telephone

Street address

City

State

ZIP code

Employer

Business phone

Insurance coverage

Do you have dental insurance?YesNo

Do you have medical insurance?YesNo

Fees and payments

Thank you for choosing Village Pointe Oral Surgery for your surgical care. Our mission is to deliver the best and most comprehensive dental care. We make every effort to keep down the cost of your oral surgical care. Any new or ongoing visit may incur a fee. An ESTIMATE of the charge for any procedure or surgery you may require will be given to you upon request.

If we are in network with your insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company.

You will be responsible for all collection costs, attorneys fees, and court costs. Returned Check Fee is 30 dollars. If prepaid services are not performed for any reason — the patient is subject to the following fees: CareCredit 16 percent reversal fee and 5 percent for Credit Card charges. These fees will be subtracted directly from any refund issued.

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

I have read and agree to the fees and payment terms above, including my authorization for the release of information necessary to process my claim and for payment to this doctor of the benefits otherwise payable to me.

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Health history

Answer the medical questions so the surgical team can plan your care safely.

Lab values

INR / date

A1C / date

Other lab values

Reviewed by, Witness, and Doctor are completed by the office.

Medication

Any medication, drugs, or pills?YesNo

Additional health information

Is there a possibility of pregnancy?YesNo

Are you taking birth-control pills?YesNo

Are you nursing?YesNo

Emergency contact name

Emergency contact relationship

Emergency contact telephone

Is your appointment today due to an injury?YesNo

Review and sign

Review what you entered, complete the authorization fields, and sign below.

Certification and signature

Required before submitting. Read the authorization below, check the certification box, type your full name, and adopt it as your signature.

Authorization and privacy

I certify that I am the patient or legal guardian/parent completing this form. I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment.

Privacy Notice Release

My personal health information is private and confidential. I understand that my doctor and his / her staff work very hard to protect my privacy and preserve the confidentiality of my personal health information. I understand that my doctor and his / her staff may use and disclose my personal health information to help provide health care to me, to handle billing and payment, and take care of other health care operations. There will be no other uses and disclosures of this information unless I permit it. However, I understand that sometimes the law may require the release of this information without my permission.

I can ask my doctor to limit how my personal health information is used or disclosed to carry out treatment, payment, or health care operations. I understand that my doctor may deny my request. If my doctor does agree to my request, I understand that my doctor and his / her staff would follow the agreed limits.

I may cancel this consent at any time by doing the following:

1. Signing and dating a written request to your doctor specifying what information you wish to restrict and to whom the restriction applies. You will receive a written response to your request.

2. Writing, signing, and dating a letter to my doctor directly. If I write a letter, it must say that I want to cancel my consent to authorize the use and disclosure of my personal health information for treatment, payment, and healthcare operations.

If I cancel this consent, my doctor and his / her staff do not have to provide any further care services to me.

My doctor has a detailed document called the “Notice of Privacy Practices”. It contains more information about the policies and practices protecting my privacy. I understand that I have the right to read the “Notice” before signing this agreement. My doctor may update this “Notice”. If I ask, my doctor or his / her staff will provide me with the most current “Notice” and the current “Notice” will always be available at my doctor’s office. Read the current Notice here: Notice of Privacy Practices (2026).

Print patient or guardian name

I give permission for the following individuals to have access to my private health information:

Authorized person 1 — name and phone

Authorized person 2 — name and phone

Authorized person 3 — name and phone

Authorized person 4 — name and phone

We may send private health information such as appointment confirmation, procedure instructions and test results to your email, your cell phone via text, your answering machine and / or your voicemail. If you choose to opt out of one of these methods, please mark below:

EmailTextAnswering machineVoicemail

I certify the information is complete and accept the examination, authorization, and privacy statements above. 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 health information to carry out treatment, payment and healthcare options.

Patient or guardian signature

Signature date

Type your full name

This is how your signature will appear.

By clicking Adopt, I agree that this is my legal signature.

Type your full name, check how it looks below, then choose “Adopt this signature.” The form cannot be sent until the signature is adopted.

Patient Registration Form