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.
Our online form uses Adobe Acrobat Reader 5 or greater 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 least version 5 of the plug-in to successfully use our online form.
You must open and submit the form in a Safari Browser with the latest Mac operating system. It is also important to have the latest version of Adobe Acrobat Reader on your computer in order to submit your form to our office correctly, please download the free plug-in from Adobe’s web site.
YOUR FIRST VISIT
Your initial appointment will consist of a consultation explaining your diagnosis and treatment options. Occasionally, surgery can be performed the same day as the consultation. However, a complex medical history or treatment plan will require an evaluation and a second appointment to provide treatment on another day.
Please assist us by providing the following information at the time of your consultation:
Your surgical referral slip and any X-rays if applicable.
A list of medications you are presently taking.
If you have medical or dental insurance, bring the necessary completed forms. This will save time and allow us to help you process any claims.
IMPORTANT: All patients under the age of 18 years must be accompanied by a parent or guardian at the consultation visit.
A pre-operative consultation and physical examination is mandatory for patients undergoing IV anesthesia for surgery. Please have nothing to eat or drink 8 hours prior to your surgery. You will also need an adult to drive you home.
Please alert the office if you have a medical condition that may be of concern prior to surgery (i.e., diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever, etc.) or if you are currently taking any medication (i.e., heart medications, aspirin, anticoagulant therapy, etc.)
For your convenience, we accept most of the major credit cards. We deliver the finest care at the most reasonable cost to our patients, therefore payment is due at the time service is rendered unless other arrangements have been made in advance. If you have questions regarding financial information and your account, please contact us at 772-461-9700 . Many times, a simple telephone call will clear any misunderstandings.
Aetna, BlueCross BlueShield, Corvel, Medicare, One Source, United Healthcare, CarePlus, Cigna, BeechStreet, Coventry, Well Care Medicare, Ammerigroup, Great West.
This is not a complete listing. Most major insurances accepted. Please call with our office to check your insurance plan coverage.
Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage.
We will send you a monthly statement. Most insurance companies will respond within four to six weeks. Please call our office if your statement does not reflect your insurance payment within that time frame. Any remaining balance after your insurance has paid is your responsibility. Your prompt remittance is appreciated. We can make arrangements for a monthly payment plan but that must be implemented prior to the actual procedure.
At Florida Institute of Oral and Maxillofacial Surgery, we make every effort to provide you with the finest surgical care and the most convenient financial options. To accomplish this goal, we work hand in hand with you to maximize your insurance reimbursement for covered procedures. If you have any problems or questions, please ask our staff. They are well informed and up-to-date. They can be reached by phone at 772-461-9700 . Please call if you have any questions or concerns regarding your initial visit. Please bring your insurance information with you to the consultation so that we can expedite reimbursement.
Congratulations to Koyama Takashi DMD PHD PA for winning the 2015 Patients' Choice Awards in Fort Pierce Dentist
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Florida Institute of Oral and Maxillofacial Surgery (a.k.a FIOMS or Florida Institute of OMS)
2402 Frist Blvd
The Lawnwood Medical Park I
Ft. Pierce, FL 34950
Phone: (772) 461-9700