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Patient Registration Form


You may preregister with our office by filling out our secure online Patient Registration Form
After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

ENGLISH:


ESPAÑOL:

Technical Note: *Once reviewed, click the button above to register.

Mac Users
Please use Safari for filling out the registration form.
CLICK HERE TO REVIEW STEP BY STEP INSTRUCTIONS

PC Users
Please use Internet Explorer for filling out the registration form.  Our online form uses the latest Adobe Acrobat Reader plug-in to conveniently submit the form from home or work. Please download the free plug-in from Adobe's web site if it is not already installed on your system. It is important that you have at the latest version of the plug-in to successfully use our online form.


Privacy Policy Form

This form, Notice of Privacy Practices, presents the information that federal law requires us to give our patients regarding our privacy practices.

                 •  English

                  •  Español


Doctor's Referral Form

Please download and fill-out our Referral Form.  After you have completed the form, please make sure to bring it on your first visit to our office. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.


                  •  Download Doctor's Referral Form
                       (Please right-click the link and save to your computer.)

Digital Signature Note:

Doctors must digitally sign the referral form. Please click Sign Here and follow the directions to setup a new digital signature.  If you have any questions, please feel free to contact support at: support@oralsurgerystx.com

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