Patient Referral Forms
Your initial appointment at Shelbourne & Associates will consist of a consultation with one of our surgeons. During this consultation we discuss your concern or problem, review your medical history, accumulate any additional information such as x-ray imaging, models, pictures, and then determine your diagnosis. For complex plans or clarification of treatment we may pursue further communication with your referring doctor and more advanced 3-dimensional imaging.
Once the diagnosis is determined, a course of treatment is carefully designed and discussed with you.
Please assist us by providing the following information at the time of your consultation:
- A list of current medications
- Medical and/or dental insurance information.
- Your referral forms and any x-rays
IMPORTANT: All patients under the age of 18 years of age must be accompanied by a parent or guardian at the consultation visit.
A preoperative consultation and physical examination is mandatory for patients undergoing IV anesthesia for surgery. Please alert the office if you have a medical condition that may be of concern prior to surgery (i.e., diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever, etc.) or if you are currently taking any medication (i.e., heart medications, aspirin, anticoagulant therapy, etc.).
We deliver the finest care at the most reasonable cost to our patients, therefore payment is due at the time service is rendered unless other arrangements have been made in advance. For your convenience, we accept Visa, MasterCard, and Discover. Our receptionist can discuss other available financing options if needed. Please consult with our receptionist or Patient Account Manager to address any questions/concerns you may have by calling us at 843-853-5859.
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. Most insurance companies will respond within four to six weeks. Please call our office if your statement does not reflect your insurance payment within that time frame. Any remaining balance after your insurance has paid is your responsibility. Your prompt remittance is appreciated. We can make arrangements for a monthly payment plan, but that must be implemented prior to the actual procedure.
We make every effort to provide you with the most convenient financial options. We will work with you to maximize your insurance reimbursement for covered procedures. If you have any problems or questions, our staff is available to help and can be reached by phone at 843-853-5859. Please bring your insurance information with you to the consultation so that we can expedite reimbursement.
Resources and Education
- American Association of Oral and Maxillofacial Surgeons
- 3Di Imaging Technology
- Roper St. Francis
- East Cooper Regional Medical Center