Register Online for Telemedicine Consultations

Patient Registration Forms for Telemedicine Appointments

Thank you for choosing our practice. We are specialists in Oral and Maxillofacial Surgery, and we take pride in being locally recognized as the practice that will make your experience as personalized and comfortable as possible. We recognize that our patients have busy and demanding schedules, we are happy to accommodate you through a Telemedicine consultation.

Prior to scheduling your initial consultation please complete the following:

Online Patient Registration

HIPAA Consent Form

Medicare Beneficiary Form

Telemedicine Consent Form

When you click the “Submit” button to finish submitting your Online Patient Registration, you will then need to securely upload and transmit images of the following:

  • Both sides of all medical and dental insurance cards.
  • Photo ID.
  • Any available x-rays you have received from your dentist. If you do not have an x-ray, please ask your dentist to forward your x-ray to us. Alternatively, we can schedule you for a short visit to obtain an x-ray at any of our offices at your convenience.
  • If you were referred to us by a dentist, please upload any correspondence or referrals that the dentist gave you regarding treatment.
  • If you have a Keystone HMO insurance plan, please call your primary care physician and request that they submit a referral to see us. Our NPI # is 1588896815. Your doctor will need this number in order to submit the referral.

Once we have received the above information, one of our staff members will reach out to you to discuss a convenient date and time to have a Telemedicine consultation. We will send you a direct link that will enable you to enter our virtual waiting room with one of our doctors. *Please note that a specialist copay may be required by your insurance company and you will be directed to pay at that time from whichever device you are using.

For assistance, please call our office at Doylestown Office Phone Number Philadelphia Office Phone Number (215) 938-7860.