Online Registration Online Registration Form Appointment Patient Information Guarantor Information Medical History HIPAA Appointment Type * Same day Consult & Surgery Consultation Only Imaging: CBCT / Panorex Section Please Choose * I have made an appointment already I need to make an appointment Reason for Visit * Teeth Extraction Treat Pain & Swelling Biopsy OtherOther Reason for Visit * Teeth Extraction Dental Implants Bone Grafting Teeth Exposure Biopsy Treat Pain & Swelling Jaw Surgery TMJ and Facial Pain OtherOther Preferred Anesthesia Option: * IV sedation to be asleep during procedure Nitrous Oxide / Laughing Gas for relaxation during procedure Local Anesthesia for numbness only Preferred Date (mm/dd/yyyy) * Date will be be reviewed and confirmed per availability by our scheduling coordinator. Insurance (Check to Acknowledge) * We would like to inform you that our practice is not affiliated with any insurance companies and is considered an out-of-network provider. However, many insurance plans offer comparable benefits for both in-network and out-of-network services, so the difference in your out-of-pocket costs is often minimal. We will provide you with complete insurance claim packet and supporting documents for direct reimbursement from your insurance provider. If you are human, leave this field blank.