Patient Registration

New Patient Forms

  • Read the information below and then click the blue button at the bottom of the page to open the registration form.  Make sure that you click “SUBMIT” when you are finished with online registration and we will have you sign the form when you check-in for your appointment.  YOU DO NOT NEED TO PRINT THE REGISTRATION FORM.
  • Patients undergoing Intravenous Anesthesia (IV Deep Sedation / General Anesthesia) should wear a short-sleeved shirt.  Do not wear flip-flops or high heels.  You must not eat anything for 6 hours before your scheduled surgery.  Clear liquids are okay to consume up to 2 hours before surgery. You may take all of your regular medications with a sip of water even if it falls within the 6 hours before your surgery time.  You must have a driver who remains in the building during your surgery.
  • Patients under 18 years of age MUST have a parent or legal guardian present during the surgical appointment.
  • BRING THE FOLLOWING ITEMS WITH YOU TO YOUR APPOINTMENT:
  1. Insurance card(s) or insurance claim form.  An explanation of benefits (EOB) from your general dentist will also be acceptable.
  2. Driver’s license or other government issued ID card (if available)
  3. Form of payment
  • If you provide us with your dental insurance information, we will collect 20% of the total charges on the day of your procedure. THIS IS AN ESTIMATE of your total financial responsibility as determined by your insurance contract.  We will file the insurance claim with your insurance company.  Once they have paid us we will either send you a bill for the remaining balance or a refund if your insurance has paid more than we had estimated at the time of surgery.  Please contact your insurance company or your Human Resources Department if you have questions regarding insurance deductibles, maximum annual coverage or the amount of your annual benefit still available for this calendar year.  The phone number for your insurance company is found on the back of your insurance card.  Dental insurance benefits have a yearly maximum and if all of it has been used, you will be responsible for 100% of the total charges for our services.  If you still have questions, please contact our billing office at 573-443-0466
  • We will contact you 1-2 days before your procedure to confirm your appointment.  You may respond to this email or contact our office if you have any questions.

New To Our Office?

Ready to Schedule your Consultation? Call Columbia Office Phone Number 573-443-0466 today!