Patient Registration

We encourage you to 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. If you like, you can also print a copy and bring it with you, as a backup. On your first visit to our office, we should have your completed form available for your signature.

Also, New York State requires that any prescriptions you might need be transmitted electronically to your pharmacy. In an effort to streamline this process, please be prepared to supply us with the name, address, and telephone number of your preferred pharmacy. And, when you check in for your appointment, please let us know your preferred method of contact (phone, text, or email).

The security and privacy of your personal data is a primary concern and we have taken every precaution to protect your information. Thank you and we look forward to serving you!

In an effort to remain compliant with the ADA (Americans with Disabilities Act), if you are having trouble filling out this form please contact our office during business hours at Oral and Maxillofacial Surgery of Nassau & Queens, LLP Phone Number (516) 437-2666 and we can assist you.

Online Patient Registration Form