Patient Information
Responsible Party
Primary Dental Insurance Information
Primary Medical Insurance Information
Permission for Record and Examination:
  • I authorize and give my permission to Dr. Gallagher to obtain permanent records in the form of study models, radiographs and photographs for examination, diagnosis, treatment planning and post-treatment evaluation(s).
  • In turn, I will inform Dr. Gallagher of all details of my medical history, as these may affect the doctor’s diagnosis and treatment plan.
  • I understand there are possible complications of all forms of treatment, as well as no treatment, and I am free to inquire into the nature and ramifications of these, if I so desire.



The information provided enhances our team’s ability to meet your healthcare needs more effectively. Thank you for filling out the form completely.

Please arrive on time for your appointment

If you are 10 minutes past your appointment time we will have to reschedule.

Patient Medical History
Are you allergic to any drugs or medications? YesNo
If YES, which?
What medications make you sick?
Have you ever been hospitalized or had an operation? YesNo
If YES, please explain:
Do you smoke?
Tobacco use? (dip, etc.)
Do you drink alcohol?
A history of alcohol abuse?
Have you ever had chest pains/angina?
Heart attack(s)
Have you ever had hemophilia?
Have you ever had kidney disease or tumors?
Have you ever had kidney trouble?
Have you ever had diabetes?
Have you ever had sinus infection/hay fever?
Have you ever had an ear infection?
Have you ever had hay fever or other allergies?
Have you ever had breathing/lung problems?
Have you ever had a heart murmur?
Have you ever had a persistant headache?
Have you ever had prolonged bleeding?
Have you ever had venereal disease?
Have you ever had thyroid trouble?
Are you pregnant?
Do you wear contact lenses?
Have you ever had asthma?
Have you ever coughed up blood?
Have you ever had high blood pressure?
Have you ever had low blood pressure?
Fainting spells
Infectious mononucleosis?
Have you ever had glaucoma?
Have you ever taken steroids?
Have you ever had an eye infection?
Have you ever received medicine for seizures?
Have you ever had seizures or epilepsy?
Have you ever had tuberculosis?
Have you ever had rheumatic fever or heart disease
Have you ever had yellow jaundice?
Have you ever had AIDS, ARC, or HIV?
Have you ever had a serious head or facial injury?
Have you ever been knocked unconcious?
Contagious diseases?
Have you ever received medicine for blood clots?
Damaged heart valves/mitral valve prolapse?
Eye disease/glaucoma?
Chronic cough?
Sleep apnea/CPAP?
Blood transfusion?
Bruise easily?
Hepatitis, jaundice, or liver disease?
Stomach ulcers/acid reflux
Delay in healing?
Are you on a diet?
Have you ever taken diet pills?
Have you ever had problems with anesthesia?
Low blood sugar?
Irregular heartbeat?
History of drug abuse?
Blood disorder such as anemia?
Bleeding tendency/abnormal bleeding?
Sexually transmitted disease?
Tumor or growth?
Have you ever had bronchitis or pneumonia?
Mental health problems/anxiety/depression?
Any natural product, herbal supplement or homeopathic remedy?
Are you taking or have you ever taken bone density meds or bisphosphonates such as Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Xgeva, Prolia, or Reclast in the past 12 years?
Have you ever received medicine for nervous or psychiatric disorders?
Have you ever had radiation therapy treatment for tumors or cancer?
Have you ever had cancer/radtiation therapy/chemotherapy?
Date of last physical exam:
List the names of doctors who have treated you within the past 2 years:
Financial/Insurance Policy

Our practice has made a commitment to provide the highest quality healthcare services to our patients. The following financial/insurance policy and payment options outline the method of payment that is expected for patients undergoing oral maxillofacial surgery. This policy has been prepared to prevent misunderstandings between the patient and this office regarding the payment and collection of fees.

Dental/Medical treatment is an excellent investment in an individual’s medical and psychological well-being. It is the patient’s responsibility to insure that any and all required, valid authorization(s) and/or referrals have been received prior to your initial consultation and/or surgery. This will require you to contact your insurance company to determine if this is an essential step stated in your benefit plan prior to coming into our office. As a courtesy to our patients our Financial Coordinator(s) will submit your claim(s) to your primary insurance company. Unfortunately we do not handle appeals; we will provide you with the necessary items to submit to your insurance company.

Tri-Care/Medicare (Opt-Out):
Patients are required to submit their own Tri-Care claim(s) our office does not submit TRI-CARE claim(s). Medicare patients agree to be responsible for payment in full for the services provided here in our office and they acknowledge that doctor WILL NOT submit a Medicare claim (nor will the patient) and that no Medicare reimbursement will be provided. (MEDICARE PATIENTS ARE REQUIRED TO SIGN AN OPT-OUT FORM STATING THEY AGREE AND UNDERSTAND PRIOR TO SEEING THE DOCTOR).

Please understand we do collect fees in full regardless of the insurance coverage or approval whether in writing or otherwise. Being sensitive to the fact that different people have different needs in fulfilling their financial obligations, we are providing the following payment options. Payment(s) are accepted by cash, check, Visa, Master Card, and Discover (Excluding – American Express). Also, for your convenience, we do offer outside financing payment options with Lending Club, Prosper, and Care Credit which require prior approval.

Returned Checks:
A $105.00 service charge will be added to returned checks ($30 Merchant Fee plus $75 Hot Check Fee). The amount must be paid by cash, cashiers check, or money order within seven days of notification. Failure to do so may result in prosecution.

The major goal of this office is to provide the very finest oral and maxillofacial surgery care at the lowest cost consistent with that quality. Please contact our office should you have addition questions/concerns in regards to our Policies.

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