• 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.

  • I consent to this office to contact me in the following manner (All Options are Preferred):*
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  • Marital Status
  • DATE OF BIRTH:*
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  • IF PATIENT IS MARRIED

  • RESPONSIBLE PARTY

    (If patient is under 18 years of age, please provide parent/guardian’s information)

  • DO YOU HAVE DENTAL BENEFITS?*
  • DO YOU HAVE MEDICAL INSURANCE?*
  • MEMBER DATE OF BIRTH:
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  • 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.

  • PLEASE COMPLETE THE MEDICAL HISTORY

  • Have you received or currently taking bone enhancement medication?*
  • Have you ever been hospitalized?*
  • Have you ever had surgery?*
  • Have you been treated by a physician or dentist in the last year?*
  • Have you ever had an injury to your face or jaw?*
  • Do you use tobacco*
  • Have you ever used tobacco?*
  • Alcohol consumption?*
  • HAVE YOU EVER HAD ANY OF THE F0LLOWING ILLNESS?*
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  • Have You Experienced Any Of The Following Symptoms?*
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  • Have You Experienced Any of The Following?*
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  • Please indicate if you ever experienced an unusual or allergic reaction to any of these medications?
  • Allergic Reaction To Sedatives?*
  • Allergic Reaction To Propofol?*
  • Allergic Reaction to Narcotics?*
  • Have You Experienced an unusual / allergic reaction to Local Anesthetic*
  • Allergic reaction to Epinephrine?*
  • Allergic Reaction to Other Medications?*

  • 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.
  • Date
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  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    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.

  • Date:
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  • ARE YOU ENROLLED OR RECEIVING MEDICARE?*
  • Medicare Patients

    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.

  • Date:
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  • THANK YOU

    FOR COMPLETING THE PATIENT REGISTRATION.

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