Patient Registration
 
Patient Information
 
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Mandatory Fields (*)

Today's Date:
* First Name:  
* Last Name:  
SSN:
* DOB:
Age:
Marital Status:
* Address Line 1:  
Address Line 2:
* City:  
* State:
* Zip:  
* Phone (H): (xxx) xxx-xxxx  
Phone (W): (xxx) xxx-xxxx
Phone (C): (xxx) xxx-xxxx
* E-mail:  
Contact Method:
Employer:
Occupation:
* General DDS:  
Physician:
* Referred By:  
 
Guarantor Insurance Information
 
First Name:
Last Name:
SSN:
DOB:
Age:
Marital Status:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Phone (H): (xxx) xxx-xxxx
Phone (W): (xxx) xxx-xxxx
Phone (C): (xxx) xxx-xxxx
E-mail:
Contact Method:
Employer:
Occupation:
Driver's License #:
Dental Insurance:
Policy #:
Group #:
Medical Insurance:
Policy #:
Group #:
Relationship to Patient:
Panoramic X-Ray Authorization
 
Most procedures, including wisdom teeth extractions and dental implants, require a panoramic x-ray for proper diagnosis. This panoramic x-ray must be within 6 months of surgery. The fees are due at time of service. Your Insurance may or may not allow benefits for x-rays due to annual limits or other reasons. We will provide you with necessary claim forms for reimbursement directly to you. Please initial here to consent:
 
Consultation Authorization
 
A full consultation and evaluation is necessary for many conditions and prior to many procedures. The consultation fee is due on the day of appointment. Your Insurance may or may not allow benefits for consultations due to annual limits or other reasons. Please initial here to consent for consultation:
 
H. Ryan Kazemi, D.M.D. Oral & Maxillofacial Surgery
4825 Bethesda Avenue • Suite 310 • Bethesda, MD 20814
(t) 301.654.7070 • (f) 301.654.7050 • (e) info@facialart.com