Patient Registration

DOUGLAS GALEN D.D.S.
Oral & Maxillofacial Surgery
Diplomate of the American Board of Oral and Maxillofacial Surgery

Please accuratly complete. This is important for our records and your health.
Last*
First*
Middle
Street*
City*
State*
Zip Code
Home Phone
Cell
Email
example@example.com
I consent to this office to contact me in the following manner (All Options are Preferred):

I consent this office to contact via cell phone numberI consent this office to contact via text messageI consent this office to contact via EmailI consent to speak with family member regarding appointments, insurance and my account
Mark One:*

MissMs.Mrs.Mr.Dr.Child
Marital Status

MarriedSingleDivorcedWidowed
DATE OF BIRTH:*

MonthDayYear
Date
Age:
SOCIAL SECURITY NO.:
OCCUPATION:
EMPLOYER:
BUSINESS ADDRESS
CITY:
BUSINESS TELEPHONE:
IF PATIENT IS MARRIED
NAME OF SPOUSE:
SOCIAL SECURITY NO.:
OCCUPATION:
SPOUSE EMPLOYER:
SPOUSE ADDRESS OF EMPLOYMENT:
SPOUSE TELEPHONE:
RESPONSIBLE PARTY

(If patient is under 18 years of age, please provide parent/guardian’s information)
PARENT / GUARDIAN NAME:
PARENT / GUARDIAN SOCIAL SECURITY NO.:
PARENT / GUARDIAN OCCUPATION:
PARENT / GUARDIAN EMPLOYER:
PARENT / GUARDIAN ADDRESS:
PARENT / GUARDIAN TELEPHONE:
PRIMARY PHYSICIAN:
PHYSICIAN TELEPHONE:
DENTIST:
DENTIST TELEPHONE:
DO YOU HAVE DENTAL BENEFITS?*

YesNo
Dental Insurance Company Name
DO YOU HAVE MEDICAL INSURANCE?*

YesNo
Medical Insurance Company Name
NAME OF POLICY HOLDER:
SSN OR MEMBER ID :
MEMBER DATE OF BIRTH:

MonthDayYear
Date
Name & Policy Number of Secondary Insurance
Insurance Disclaimer

We are not providers for any dental, medical or medicare insurance carriers. As a courtesy we will submit a claim to your insurance company (except medicare) and reimbursement will be directed to the insured.
Doctor or Person who referred you to our office:
PLEASE COMPLETE THE MEDICAL HISTORY
Reason for your visit today
Please list any medications that you take regularly:
Have you received or currently taking bone enhancement medication?*

YesNo
Bone Enhancement Medication:
Have you ever been hospitalized?*

YesNo
Describe Hospitalization:
Have you ever had surgery?*

YesNo
What Type of Surgery?:
Describe any illness for which you are being treated:
Have you been treated by a physician or dentist in the last year?*

YesNo
What have you been treated by a physician or dentist for?
Have you ever had an injury to your face or jaw?*

YesNo
Describe the injury:
Do you use tobacco?*

NoneCigarettesCigarPipechew / Snuff
Have you ever used tobacco?*

YesNo
IF YES: Years of tobacco use:
IF YES: Years Discontinued tobacco:
Alcohol consumption?*

NoneLightModerateHeavy

HAVE YOU EVER HAD ANY OF THE F0LLOWING ILLNESS?*

	YES	NO
Heart Disease
Hypertension
Heart Attack
Heart Murmur
Rheumatic Fever
Heart Valve Replacement
Stroke
Excessive Bleeding or Brusing
Asthma
Sinus Infection
Diabetes
Glaucoma
Cancer
Radiation Therapy
Chemotherapy
Kidney Disease
Liver Disease
AIDS / HIV
TMJ
Psychiatric Treatment

Have You Experienced Any OF The Following Symptoms?*

	YES	NO
Chest pain upon exertion?
Shortness of Breath on mild exertion (climbing stairs)?
Do you faint easily?
Does your jaw click or pop?
Do you have frequent headaches?
Is it difficult to open you mouth wide?
Are you dissatisfied with your smile, bite or facial appearance?
Do you wear contact lenses?
Women: Are you pregnant? Do you think you might be pregnant?
Women: Do you take birth control pills?

Please indicate if you ever experienced an unusual or allergic reaction to any of these medications?

PenicillinErythromycinTetracyclineKeflexSulfaAspirin
Allergic Reaction To Codeine?*

YesNo
Briefly describe reaction to Codeine
Allergic Reaction To Vicodin?*

YesNo
Briefly describe reaction to Vicodin
Allergic Reaction To Percodan / Percocet?*

YesNo
Briefly describe reaction to Percodan / Percocet / Vicodin
Have You Experienced an unusual / allergic reaction to Local Anesthetic*

YesNo
Name of anesthetic allergic to:
Briefly describe the local anesthetic allergic reaction:
Allergic reaction to epinephrine?:*

YesNo
Briefly describe the epinephrine allergic reaction:
Describe in a few words
Allergic Reaction to Other Medications?*

YesNo
Other Medication Allergic to:
Name
I hereby certify that the above information is true and accurate and there have not been any omissions from my medical history. I consent to the taking of clinical photographs for the purpose of treatment and/or educational use. I authorize the release of any information to my insurance com panies. I understand that Dr. Galen is not a provider for any medical or dental insurance plans and is not a Medicare provider. I understand that I will be financially responsible for all charges incurred and payment is due at the time that services are rendered. Should it be necessary to take any action against any of the parties to this agreement to enforce the provisions thereof or to take any action which is related to or arises out of this agreement, Douglas M. Galen, D.D.S. shall be entitled to all cost and expenses including but not limited to attorneys’ fees, service charges and collection agencies fees incurred therein but not to exceed $5,000. Accounts extending over thirty days will be charged 0.833% interest per month.
Patient Signature / Legal Guardian Signature*

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Date

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Date
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
We are committed to protecting your privacy and ensuring that your health information is used and disclosed appropriately. Our Notice of Privacy Practices identifies all potential uses and disclosures of your health information by our practice and outlines your rights with regard to your health information. Please sign the form below to acknowledge that you have received our Notice of Privacy Practices.

I acknowledge that I have received /reviewed a copy of the Notice of Privacy Practices of Douglas M. Galen, D.D.S.
Signature*

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Date:

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Date
If Signature is a Personal Representative:
Relation:
Medicare Patients

Notice of Private Contract
By signing this contract I understand and agree that I will not submit (or request that my oral and maxillofacial surgeon submit) a claim to Medicare or its agents for services provided by Douglas M. Galen D.D.S., even if such services would otherwise be covered.

I agree to be fully responsible, through insurance or otherwise, for payment of services rendered by Douglas M. Galen D.D.S. and I understand that no claims will be submitted to Medicare and no Medicare reimbursement will be provided for these services.

I understand that there are no limits specified by Medicare as to the amounts that may be charged by the oral and maxillofacial surgeon for services provided.

I understand that Medigap plans do not, and other health and medical care insurance plans may elect not to, make payments for such services.

I understand that I have the right to have services provided by other oral and maxillofacial surgeons or other practitioners for whom Medicare payment would be made, and that I am not compelled to enter into private contracts that apply to covered care furnished by other health care professionals who have not opted-out.

I understand that Douglas M. Galen, D.D.S. is not excluded from participation in the Medicare program under Section 1128 of the Social Security Act or pursuant to any other legal authority.
Signature

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Date:

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Date
Should be Empty:

IF PATIENT IS MARRIED

Insurance Disclaimer

PLEASE COMPLETE THE MEDICAL HISTORY

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Medicare Patients