Online Registration Online Registration Form If you are human, leave this field blank. Appointment Patient Information Guarantor Information Medical History HIPAA For safe submission of your registration forms online Appointment Type * Consultation Surgery Same day consult & surgery Follow up Section Please Choose * I have made an appointment already I need to make an appointment Reason for visit * Teeth extraction Dental implants Bone grafting Exposure teeth Jaw surgery Biopsy Pain and swelling CBCT TMJ Follow up OtherOther Insurance We do not participate with any insurance plans. For claims submission and benefits, please contact our financial coordinator for assistance. Preferred Date (mm/dd/yyyy) * Preferred Time * AM PM