Pre-register Online

Online Bill Pay

Complete and submit the online Pre-Registration Form. If you have any questions, please call 405-307-2031.

Required indicates a required field.

Type of Service

Service/Procedure Information

Procedure/Test

Date of Procedure

(MM/DD/YYYY)

Physician's Last Name

Physician's First Name

(Please enter "Dr." if First Name is unknown)

Patient Information
Please enter full legal name below

Last Name

First Name

Street Address

City

State

ZIP Code

Phone Number

Last 4 Digits of Social Security Number

Date of Birth

Gender

Race

Marital Status

Email Address

Preferred Pharmacy

Patient Employment
(If unemployed, please type "none" in both Employer Name and Work Phone Fields)

Employment Status

Employer Name

Employer Phone

Employer Address

Employer City

Employer State

Employer Zip

Person to Notify

Last Name

First Name

Relation to Patient

Street Address

City

State

ZIP Code

Home Phone

Work Phone

Financial Responsibility Information

Is the Patient the Primary Insurance Holder?

Policy Holder Relationship To Patient

Policy Holder Last Name

Policy Holder First Name

Policy Holder Address

Policy Holder City

Policy Holder State

Policy Holder ZIP

Policy Holder Social Security Number

Policy Holder Date of Birth

Policy Holder Employer Name

Policy Holder Employer Address

Policy Holder Employer City

Policy Holder Employer State

Policy Holder Employer ZIP

Insurance Information
(If uninsured, please type "none" in the Insurance Company Name)

Insurance Company Name

Insurance Company Policy Number

Insurance Group Number

Insurance Company Phone

Insurance Company Address

Insurance Company City

Insurance Company State

Insurance Company ZIP

Insurance Company Authorization Number

Insurance Card Image You may optionally upload an image of your insurance card. JPG, PNG, and GIF formats are allowed. Please limit the size of the file to 10MB.

Secondary Insurance Information
(If uninsured, please type "none" in the Insurance Company Name)