Date:

Name Birthdate
Email
Address City State Zip
Sex M F Widowed Single
Divorced
Address City State Zip
Employer
Phone
Name of person
Responsible for this account
Address
Birthdate
Yes No Email
SS #
Address City State Zip
Address City State Zip
How much is your deductible?
Name of Insured
Birthdate SS #
Address City State Zip
Address City State Zip
How much is your deductible?
Thank you for trusting us with your dental care.
We Promise to do our best to provide you with
the finest care available. If you have any
questions, please do not hesitate to call us.
Employer/School
PATIENT INFORMATION
Minor
Partnered
Home Phone ( )
RESPONSIBLE PARTY
INSURANCE INFORMATION
Relation to Patient
Home Phone
Spouse or Parent name Work Phone ( )
Whom may we thanks for referring you?
Person to contact in case of an emergency ( )
Employer Work Phone ( )
Current Patient in our office?
( )
Driver's License # Cell Phone ( )
Employer Work Phone ( )
Relation to Patient
Date Employed
Group Number
How much have you used? Max Benefit?
( )
ADDITIONAL INSURANCE
Relation to Patient
Date Employed
Patient #
Insurance Company
Insurance Company
Name of Insured
Birthdate
( ) Employer/School Phone
Cell Phone ( )
Group Number
How much have you used? Max Benefit?
Employer Work Phone
Married
Separated
Address
Yes No
Yes No Nursing Yes No
Arthritis, Rheumatism Liver Disease
Artificial Heart Halves Pacemaker
Artificial Joints, Pins, etc Radiation Tyreatments
Asthma Respiratory Disease
Back Problems Shortness of Breath
Bleeding Abnormally Skin Rash
`
Blood Disease Stroke
Cancer Thyroid Problems
Chemical Dependency Tobacco Habit
Chemotherapy Tonsillitis
Circulatory Problems Tuberculosis
Congenital Heart Problems Ulcer
List medications you are currently taking and the correlating diagnosis: Allergies
DENTAL HISTORY
MEDICAL HISTORY
Bad Breath Grinding teeth
Bleeding gums
Reason for today's visit Date of last dental care
Former Dentist Date of last dental X-rays
Check if you have had problems with any of the following:
Check if you have or have had any of the following:
Sensitivity when biting
(women only) Are you Pregnant?
Acid Reflux Disease Jaw Pain
Physician's name Date of last visit?
Have you had any serious illness or operations?
If yes, please describe
Clicking or popping jaw
Food collection between teeth
Loose teeth or broken fillings
Periodontal treatment
Sores or growths in your mouth
Heart Problems
Hemophilla
Hepatitis
Glaucoma
Headaches
Heart Murmur
Cough, Persistent
Diabetes
Epilepsy
Fainting
Anemia
Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient
Date
Sensitivity to hot
Sensitivity to cold
Sensitivity to sweets
Dr. Tristan Galloway may use my health care information and may disclose such information to the above-named insurance compan(ies) and their agents for the purpose of
obtaining payment for services and determining insurance benefits or the benefits payable for related services.
Signature of Patient, Parent, Guardian or Personal Representative
How often do you floss? How often do you brush?
To the best of my knowledge, the above information is complete and correct. I understand that is is my responsibility to inform my doctor if I, or my minor child, ever have a
change in health.
I certift that I, and/or my dependant(s), have insurance coverage with _________________________________________________ and assign directly to Dr. Tristan Galloway
Name of Insurance compan(ies)
all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I
authorize the use of my signature on all insurance submissions.
Kidney Disease
Payment is due in full at time of treatment unless prior arrangements have been approved.
Illegal Drug use
AUTHORIZATION AND RELEASE
Hernia Repair
High Blood Pressure
HIV/AIDS
Updated Date
Updated Date
Changes noted on Form: Patient Initials
Changes noted on Form: Patient Initials
No Change
No Change