Welcome Form | Santa Rosa Oral Surgery

Form 1 of 4

Please complete all sections of this form before your first visit to Santa Rosa Oral Surgery. Your information is submitted securely and will be reviewed by our team. If you have any questions, please call us at 707-545-4625.

Patient Information

First Name *

Middle Initial *

Last Name *

Email (To Confirm Appointments)

Phone (Primary) *

Phone (Secondary)

May we text appointment reminders *

SSN *

Date of Birth *

Age

Address *

City *

State *

Zip *

Employer

Occupation

Work Phone

Emergency Contact

Relationship

Emergency Contact Phone

Parent/Legal Guardian Accompanying Minor

First Name

Middle Initial

Last Name

Relationship to Patient

Phone (Primary)

Phone (Secondary)

SSN

Date of Birth

Employer

Work Phone

Address (If different)

City

State

Zip

Insurance Information

Primary Dental Insurance

Full Name of Insured

Relationship to Patient

Address (If different)

City

State

Zip

Insured's DoB

SSN

Employer

Insurance Company

Insurance Address

Group #

ID #

Secondary Dental Insurance (Optional)

Full Name of Insured

Relationship to Patient

Address (If different)

City

State

Zip

Insured's DoB

SSN

Employer

Insurance Company

Insurance Address

Group #

ID #

Information Release (Optional)

With the exception of your insurance and treating physicians, HIPAA restricts us from disclosing information to ANYONE without your written consent. If you wish to authorize release of information to someone (parent, spouse, friend etc.) please let us know:

Name

Relationship

Name

Relationship

I authorize and request my insurance company to pay directly to the dentist otherwise payable by me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. You have my permission to contact me via cell phone to discuss any matters related to my account or that of my dependents.

Signature of patient or responsible party (Type Full Name) *

Schedule Your Visit

Appointment Request

Take the next step toward healthier function, greater comfort, and renewed confidence with care designed around your needs. Whether you have been referred for oral surgery in Santa Rosa, CA, are exploring dental implants, or need prompt attention for wisdom teeth or extractions, our team is ready to help. We explain your options clearly, answer questions thoroughly, and make scheduling simple so you can begin treatment with peace of mind today with confidence and clarity throughout treatment.