New Patients

/New Patients
New Patients 2018-05-13T14:17:00+00:00

We are now accepting new patients! If you would like to become a patient, please fill out the online form below and submit.

Full Name *

Date of Birth (mm/dd/yy) *

Age *

Sex *

MaleFemale

Social Security Number *

Address *

Home Telephone *

Cell Phone *

Work Phone *

Extension *

Dentist *

Physician *

Referred By *

Parent Name (if patient is a minor)

Parent Address

Parent Social Security Number

Parent Phone Number

Student *

Full TimePart TimeNot

School Name

Marital Status *

SingleMarriedDivorcedLegally SeparatedWidowed

Employeed *

Full TimePart TimeRetiredNot

Employer Name

Employer Address

Emergency Contact

Emergency Phone Number



Medical Insurance

Do You Have Medical Insurance?
YesNo (Self-Pay)

Medical Insurance Co. *

ID No. *

Insurance Co. Address *

Insurance Phone Number *

Group Name *

Group Number *

Subscriber Name *

Subscriber SSN *

Address (if different from patient) *

Phone Number (if different from patient) *

Date of Birth *

Patient Relationship to Subscriber *

SelfSpouseChildOther

If Chose Other (Please indicate) *

Are You Pregnant?*

YesNo

If Yes, Estimated Delivery Date *




Dental Insurance

Do You Have Dental Insurance?
YesNo (Self-Pay)

Dental Insurance Co. *

ID No. *

Insurance Co. Address *

Insurance Phone Number *

Group Name *

Group Number *

Subscriber Name *

Subscriber SSN *

Address (if different from patient) *

Phone Number (if different from patient) *

Date of Birth *

Patient Relationship to Subscriber *

SelfSpouseChildOther

If Chose Other (Please indicate) *


Do you have Secondary Insurance

YesNo

Type *

MedicalDental

Insurance Company Name *

Group Name *

Group Number *

Subscriber Name *




Fees and Payment

Please remember that insurance is not a substitute for payment. Some companies pay fixed allowances for a certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid by your insurance company.

This signature on file is authorization for the release of information necessary to process my claim. I hereby authorize payment directly to the doctor named on the benefits otherwise payable to me.

There will be $50.00 charge for any returned checks. If there is a returned check, it must be paid in full, along with the $50.00 returned check fee in cash within 24 hours or it will be turned over to the Sheriff's Department for collection.

Signature of Patient (Parent or Guardian if Minor) *

Date *




Authorization

I authorize my surgeon and his/her designated staff to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment.

Signature of Patient (Parent or Guardian if Minor) *

Date *




Authorization for Release of Medical/Dental Records

I hereby request and authorize the release of all information regarding any physical and mental condition, as revealed by your observation or treatment, past, present or future.

This includes photocopies of medical and/or dental histories, x-ray findings, diagnosis, treatment, prognosis and financial records.

Signature of Patient (Parent or Guardian if Minor) *

Date *




Acknowledgement of Receipt of Privacy Notice

Signature of Patient or Personal Representative *

Date *

Personal Representative's relationship to Patient *




Need Help?

If you have any questions at all, feel free to contact Valerie Harris. She is able to answer any of your questions and ease any of your fears. Please contact Valerie via email at valerie@southwestoralandfacialsurgery.com
or via phone at 229.878.3610.

Locations and Contacts

Albany Office

620 Pointe North Blvd.
Albany, GA 31721

Phone: 229.878.3610


Thomasville Office

418 Remington Ave.
Thomasville, GA 31792

Phone: 229.226.4434


Tifton Office

1809 Old Ocilla Rd
Tifton, GA 31794

Phone: 229.387.7465