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Who will be responsible for your account?

Emergency Contact

Insurance Information

Primary Dental Insurance Company

Secondary Dental Insurance Company

Primary Medical Insurance Company

Secondary Medical Insurance Company

Health History

Have you had or do you currently have the following:


Are you taking any of the following?

Are you taking, or have you ever taken bone density medications, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast,
or Evista in the past 12 years?

Allergies/ Reactions

Are you allergic to, or had a reaction to any of the following:

Other Health Related Questions

Is there a family history of the following?

Please check all that apply

For Women Only

WARNING: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician for assistance regarding additional methods of birth control.

Form Completion

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member his/her staff, responsible for any errors or omissions that I have made in the completion of this form.

Fees and Payments

For your convenience, we accept cash, Certified Check/Personal Checks $500.00 or less, Visa, MasterCard, American Express, Discover, Care Credit and most insurance plans. Personal checks that are returned due to “insufficient funds” are subject to a $50.00 service fee. We deliver the finest care at the most reasonable cost to our patients, therefore payment is due at the time services are rendered. All accounts over 90 days will be considered past due. Patient agrees to pay additional charges of 18% of 1.5 monthly finance charges (or the maximum percentage allowed by law, whichever is lower) of the invoiced amount per month for any payment received by Reston Advanced Oral & Cosmetic Facial Surgery, and affiliates or employees representing or d/b/a Reston Advanced Oral & Cosmetic Facial Surgery more than 90 days from the date of invoice or bill for services. In the event collection of patient’s account is referred to an attorney, patient agrees to pay all expenses incurred by Reston Advanced Oral & Cosmetic Facial Surgery, and affiliates or employees representing or d/b/a/ Reston Advanced Oral & Cosmetic Facial Surgery in effecting payment, specifically including attorney’s fees of 33-1/3% of the principal due and owing. If you have questions regarding your account, please contact us at (571) 595-3223. Many times, a simple telephone call will clear any misunderstandings.

Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage. We will send you a monthly statement. We ask that you also realize that we do not work for an insurance company. Rather we work 100% for our patients. We feel that insurance can be a great benefit for many patients and want you to know we will do everything in our power to ensure you receive every benefit allotted in your insurance contract. However; the treatment we recommend and the fees we charge will always be based on your individual needs, not your insurance coverage.

If you need to cancel or reschedule your appointment, please call us 48 hours in advance. If you fail to do so, or are not present at your scheduled appointment, there will be a $500.00 charge.

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

HIV/Hepatitis B or C Testing

As a patient, please be advised that in accordance with Section 32.1-45.1 of the Code of Virginia, 1950, as amended, that if the provision of health care services to the patient exposes any person employed by or under the direction and control of this facility or any other healthcare provider, to the patient's body fluids in a manner which may transmit immunodeficiency virus or HIV or Hepatitis B or C viruses, then the patient will be deemed to have consented to testing for infection with HIV or Hepatitis B or C viruses, and the release of such test results to the person(s) exposed.

Privacy Policy

Click on the hyperlink to obtain a copy:

I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.


I authorize my surgeon and his/her staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers.

Office Policies Acknowledgement

I certify that I have read and understand the office policies regarding Fees & Payments, Privacy Policy and Authorization as stated above. All of my questions have been answered to my satisfaction.

If Patient is a Minor

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