Please complete the following forms and bring them with to your new patient appointment.
After clicking onto the Patient Registration Form, please print the form from the site and then manually complete it USING BLACK OR DARK BLUE INK. Please do the same with the Patient History and Medication List and bring all three forms to your appointment.
If you have questions, please contact us at 952 931-9961.
AT YOUR INITIAL APPOINTMENT, PLAN ON BEING AT OUR OFFICE ~ 90 MINUTES
Steps to take before your appointment:
Call your insurance company to determine if our clinic is in your network and what your benefits are for nonsurgical TMJ treatment.
If our doctor is not a provider for your insurance and you would prefer to be seen here, ask if you have out of network benefits and if so, what they are.
Ask your customer service representative if a prior authorization is required for any treatment you pursue after your initial appointment.
If your insurance company requires a referral from your primary clinic in order to receive insurance benefits, please contact your physician to ensure the proper steps are being taken.
ITEMS TO BRING TO YOUR 1ST APPOINTMENT
___ Any splint/nightguard, if you have one.
___ Photo identification.
___ Any panoramic x-ray taken within the last 1-2 years by your dentist.
___ Any scans your medical doctor may have, i.e. tomograms, MRI.
___ Current insurance card.
If you did not or were unable to complete the registration forms above, please include the following items to bring with you as well:
___ Name, address and phone number of your doctor and dentist.
___ List medications and dosage of each.