Patient Registration

Please choose the appropriate form to fill out

You may preregister with our office by filling out our secure online Patient Registration forms. After you have completed the appropriate form, please make sure to press the Submit button at the bottom to automatically send us your information.

Afterward you can press the download button and then print out your form to bring with you to the office. You will also have the option to securely upload and transmit images of your insurance card.

On your first visit to our office, we will have your form available for your signatures. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it. Please call our office if you need assistance: Encino Office Phone Number 818-990-5500.

Patients’ Dependents — Ages 13 to 25

Clickable button to launch a secure, online Oral Surgery Patient Registration form for Dependent Children Ages 13-25

Print Blank Form


Patients 19 Years of Age and Older

Clickable button to launch a secure, online Oral Surgery Patient Registration form for Dependent Children Ages 13-25

Print Blank Form


Patients 12 Years of Age and Younger

Clickable button to launch a secure, online Oral Surgery Patient Registration form for Dependent Children Ages 13-25

Print Blank Form

Technical Note

These downloadable registration forms are in PDF format. If you do not have Adobe Reader installed on your computer, you may download Acrobat Reader for free and use it to access these forms.

Clickable social media button to Dr Maranon's Oral Surgery Facebook page

Clickable social media button to Dr Maranon's Google+ page