• 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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  • 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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  • THANK YOU

    FOR COMPLETING THE PATIENT REGISTRATION.

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