New Patient Forms
You may print and complete this form (PDF format) from the comfort of your own home.
Our goal is to make your consultation with us informative and comfortable. You should always feel free to ask any questions about the various procedures that interest you and will be provided the opportunity to discuss these at length with Dr. Smith and his staff.
Dr. Smith is board certified in both Facial Plastic and Reconstructive Surgery and Otolaryngology-Head and Neck Surgery. He has published a large number of articles in the fields of cosmetic surgery (including rhinoplasty, chin augmentation, facelift, lip augmentation, laser resurfacing, and ear shaping surgery), reconstructive surgery (including a number of different flaps to assist in restoring the face and neck), maxillofacial trauma, and skull base surgery (including various approaches to access lesions of the skull base as well as a number of techniques to optimize appearance postoperatively).
Although we focus our effort on the face, head and neck, we routinely harvest grafts (bone, skin, cartilage, muscle, tendon) from other parts of the body to assist us in optimizing the esthestic and functional restoration of the face and facial skeleton. This allows Dr. Smith to improve appearance not only in cosmetic surgery patients, but also to enhance the return of form in reconstructive surgery patients. This includes patients suffering from congenital birth defects (cleft lip, cleft palate, skin lesions, craniofacial abnormalities) and trauma (fractures of the upper face or mandible, scar revisions). The ability to perform many types of tissue transfers, including microsurgical procedures, allows us to treat many head and neck cancers aggressively while optimizing appearance and functional ability after loss of tissue by the tumor.
Dr. Smith also provides access for most lesions of the skull base through a number of different approaches. Skull base tumors are those involving the part of the skull behind the face and below the brain. Many of the tumors in this region are benign, but may cause significant neurological problems and even death if left untreated. The goal is to remove as much of the tumor as possible without adding major new neurological deficits. Often, the best approach is the one which provides for broad exposure of the tumor and various nerves exiting the brain. These approaches may involve temporarily removing parts of the facial skeleton or moving them to the side to allow for safe access to the tumor. Once the tumor removal has been completed, the difficult task of facial reconstruction ensues. Dr. Smith focuses much of his efforts not only in accessing the tumor but, also in restoring the patient’s appearance. He has developed a number of procedures that result in significant improvements in the patient’s overall appearance
We will work with you to develop a treatment plan with which you are comfortable and allow you to make an informed decision about your surgery. Many factors need to be considered before considering surgery. We look forward to the opportunity to guide you in this process.
Your initial appointment will consist of a consultation explaining your diagnosis and treatment options. Occasionally, treatment can be done the same day as the consultation. However, a complex medical history or treatment plan will require an evaluation and a second appointment to provide treatment on another day.
IMPORTANT: All patients under 18 must be accompanied by a parent or guardian during the consultation visit.
Please alert the office if you have a medical condition that may be of concern (i.e. diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever, etc.) or if you are on any medication (i.e. heart medications, aspirin, anticoagulant therapy, etc.)
Please assist us by providing the following information at the time of your consultation:
- Your referral slip and any X-rays if applicable
- A list of medications you are presently taking
- If you have medical or dental insurance, bring the necessary completed forms. This will save time and allow us to help you process any claims.
Financial & Insurance
At the time of your initial visit, your treatment plan will be established along with an estimate of fees. We will file your insurance paperwork to help receive all entitled reimbursements. Please bring your insurance forms with you and have your portion filled out and signed to expedite the filing of your claim.
Filing your claim: Our financial secretary will be happy to discuss payment arrangements that will suit your needs. We accept cash, check, VISA, Mastercard and Discover. In order to contain billing cost we ask that all accounts be paid within 60 days from the date of service. If an account goes over 60 days a finance charge of 1.5% per month (18% per year) is added to the unpaid balance.
Our insurance coordinators deal with many insurance companies. Some companies offer up to six medical plans. Because many companies frequently change policies, it is sometimes difficult to accurately estimate our patient’s insurance co-payment. Many insurance companies will not give out fees until after the treatment is completed. As a courtesy, we ask that you keep us informed of any change to your insurance. It is important that all information about you is current.
Co-Payment: All co-payments are payable when you check in at the front desk.
If a patient comes to us with a problem that they expect to be covered by medical insurance, (biopsies, tumors, infections, deformities) they must have a referral from their primary care physician. A referral from a dentist is not adequate for medical insurance coverage. Obtaining a medical referral is the patient’s responsibility. We cannot obtain the referral for you, and the referral cannot be obtained retroactively. If you do not have a referral, we will be happy to see you on a cash basis, but your medical insurance company will not pay for your treatment.
Medicare pays us directly for your care. You are responsible for any deductible and co-insurance. If Medicare denies your procedure, you are responsible for the charges.
Private and Group Insurance
As a courtesy, we will file your insurance claims for you. Upon receipt of an insurance payment, any balance due will be billed to you. If you have deposited an excessive co-payment, it will be refunded to you.
CareCredit offers No Interest and low monthly payment options, no up-front costs, no pre-payment penalties and no annual fees so you can get what you want when you want it.
www.carecredit.com If you have any problems or questions, please ask our staff. They are well informed and up-to-date. Please call if you have any questions or concerns regarding your initial visit.