Downloadable Forms to Reduce Waiting Time

To reduce your waiting time during your visit, we have provided several forms that you can download, read (and where appropriate, complete and sign) and bring with you. Please see the instructions included on each form.

These forms require the Adobe Acrobat Reader.

New Patients

Statement of Consent for Oral Surgery — For all patients undergoing oral surgery. Please print, read and bring in with you; after your consultation with the doctor, we will ask you to sign the form and we will keep it with your records.
Statement of Consent for Oral Surgery

Patient Information and Medical Record — For all new patients. Please print, complete and bring in with you.
Patient Information and Medical Record

Notice of Privacy Practices for Protected Health Information — A summary of the rules protecting the privacy of your medical information. Please print, read carefully, complete and sign, and bring with you on your visit.
Notice of Privacy Practices for Protected Health Information

Our Payment Policy — An explanation of the payment policy of Northern Virginia Oral and Maxillofacial Surgery Associates, including options for payment and insurance filing. Please print, read carefully and sign, and bring with you on your visit.
Payment Policy

Returning Patients

Authorization to Release Health Care Information — For any patient who wants to authorize our practice to release their medical information to a third party. Please print, complete and sign, and mail or deliver to our office.
Authorization to Release Health Care Information

Patient Information and Medical Record — For returning patients whose insurance, contact or medical information has changed. Please print, complete and bring in with you.
Patient Information and Medical Record