Oral & Facial Surgery Center Online Patient Registration
Oral Surgery Patient Registration
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.
Or click HERE for a printable form to complete by hand and bring with you to our office.
By filling out our patient registration form in advance, we are able to provide you with a faster and more convenient experience upon your first visit to our office. If you have any questions about the patient registration process, please call us at Oral & Facial Surgery Center, LTD. Phone Number 815-877-0694.
WHO WILL BE RESPONSIBLE FOR YOUR ACCOUNT?
A GUARANTOR is the person held responsible for the patient’s financial account.
- The GUARANTOR is ALWAYS the patient unless the patient is a MINOR (under age 18) or an incapacitated adult.
- The GUARANTOR for a minor child is the parent or legal guardian that signs the CONSENT FOR SURGERY form and the PATIENT HEALTH HISTORY form.
- STUDENTS age 18 or older are their OWN guarantor.
- The GUARANTOR is NOT automatically the insurance subscriber or head of household.
- The “other parent” is NOT the guarantor. If the parent or legal guardian presenting the child brings a divorce decree stating the other parent is 100% financially responsible for the child’s medical bills, the guarantor will be changed to the parent designated in the divorce decree.
- Your spouse can be your guarantor ONLY if you are an incapacitated adult.
New Patient Information
- First Visit
- Financial Policy & Insurance Information
- Meet Dr. Kurt F. Jensen
- Meet Dr. Alexandria Hawkins
Thank you for choosing Oral & Facial Surgery Center. We strive to deliver the best diagnosis and treatment that our practice has to offer. We believe that these goals can be met through a continuous and open dialogue between you and our entire team.