Secure Digital Patient Registration

Milford & Derby Online Forms

We are a digital, paperless office. In order to be seen, you must preregister with our office by filling out our secure online forms for COVID-19 Pre-screening and Patient Registration. After you have completed the forms, please make sure to press the Submit button at the bottom to automatically send us your information.

Call our offices for assistance: Milford Milford Office Phone Number 203-874-1664 or Derby Derby Office Phone Number 203-734-2523

Online Patient Registration

On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Patient Privacy and Protection

We take your Protected Health Information (PHI) very seriously.  As the federal government has mandate all doctors transition to an Electronic Medical Records (EMR), Milford & Derby Oral & Maxillofacial Surgery has been a leader in becoming a paperless, all digital office.

The form to be completed is hosted on a secure server and dually encrypted by a company called PBHS.  PBHS also follows all HIPAA compliance laws regarding passing patient information online.  PBHS specifically follows The Security Rule,, which is a series of administrative, physical, and technical safeguards to assure the confidentiality, integrity and availability of electronic Protected Health Information. 

Patients are required to complete their registration forms online through a secure and encrypted website.  Failure to have completed forms will result in rescheduling of your appointment.  The forms need to be completed on the day the appointment is made in preparation for your consultation or procedure.