Thank you for helping us raise the Barr in dentistry! We will strive to provide you with the best possible dental care. To help us meet all your dental needs, please take your time to fill out this form completely. If you should have any questions, please do not hesitate to ask. We will be happy to help.
Patient Information (Confidential)
DATE:
DATE:
*
/
Month
/
Day
Year
Date
NAME:
*
GENDER:
GENDER:
DOB:
HOME PHONE:
HOME PHONE:
*
HOME PHONE:
*
ADDRESS:
STATE:
*
EMPLOYER:
*
WORK PHONE:
*
SPOUSE or PARENT'S NAME:
EMERGENCY CONTACT:
*
EMERGERNCY CONTACT PHONE:
*
WHOM MAY WE THANK FOR REFERRING YOU?
EMAIL:
example@example.com
OK TO TEXT?
YES
NO
YES
NO
Cell #:
(This is how we will confirm your appointments)
Responsible Party
PERSON RESPONSIBLE FOR ACCOUNT:
*
PERSON RESPONSIBLE FOR ACCOUNT:
*
RELATIONSHIP TO PATIENT
ADDRESS:
DOB:
SSN:
Insurance Information
NAME OF SUBSCRIBER:
*
RELATIONSHIP TO PATIENT:
*
SUBSCRIBER'S DOB:
SSN or ID#:
NAME OF EMPLOYER:
WORK NUMBER:
WORK NUMBER:
*
INSURANCE COMPANY:
*
GROUP
PHONE:
INSURANCE COMPANY ADDRESS:
ZIP:
*
DO YOU HAVE ADDITIONAL INSURANCE?
IF "YES", PLEASE COMPLETE THE FOLLOWING:
NAME OF INSURED:
INSURED'S DOB:
SSN or ID#:
NAME OF EMPLOYER:
INSURANCE COMPANY:
GROUP #:
Address
INSURANCE COMPANY ADDRESS
Street Address Line 2
CITY
STATE
ZIP
Insurance Zip____________ID#______________________________________________________ Name of Company_________________________Group#_____________________PhoneDo You Have Additional Insurance? Yes_______ No _______ If yes, please Employer_____________________________________________Work _ _ complete the following:Number__________________________Insurance Company birthday_____________________SSN or Insurance Address________________________________City_______________State_____Name of Insured____________________________________Relationship to Company_________________________Group#_____________________Phone_Patient______________________________ Insured’s _ Insurance Company Address________________________________City_______________State______ Zip
CASH - CHECK - VISA - MASTERCARDAMERICAN EXPRESS - CARE CREDIT
Payment in full is due at the time services are rendered.
INSURANCEYour insurance is a contract between you and the insurance company, and is your responsibility to know your
insurance benefits.
As a courtesy, we will bill both your primary and secondary insurance companies. We will submit your claims and assist you in any way we reasonably can to help get your claims processed. In order to do this, we must receive all the
information necessary to bill. If the information is not supplied, you will be billed, and payment in full will be your
responsibility and will be expected within 30 days or receipt of statement.
RETURNED CHECKSAny checks returned to our office due to non-sufficient funds (NSF) will be charged a fee of $35.
LAST MINUTE CANCELLATIONS OR MISSED APPOINTMENTS Our practice is dedicated to quality care and exceptional service. We respect the importance of your time and work
very hard to schedule appointments that accommodate the busy scheduling needs of all out patients. In return, we ask that patients make every effort not to change reserved dental appointments. Also, missed or broken appointments interfere with your dental treatment. If an appointment needs to be changed, we require at least a 24-hour notice so that we may accommodate other patients. If a patient cancels an appointment with less than 24-hour notice, two times, the patient will be placed on the “quick call” list. Being on the “quick call” list means our office will do everything to help the patient get scheduled if there is a same day cancellation on the schedule. Unfortunately, no advanced appointments will be made for these cases. If a patient confirms an appointment and no shows, the patient will be placed on the quick call list. If an appointment is made from the quick call list, and the patient does not show, no further appointments will be made for that patient.
PAYMENTAs a patient, or legal guardian of a minor patient, I have read and understand the financial policy stated above. I agree
to pay, promptly and in full. Any amounts due to the provider, including any amounts due for non-covered or services above the maximum allowed amount that are not payable by the insurance.
Other payment options and payment plans may be available upon request.
I (we) herby authorize Barr Family Dentistry to furnish my (our) Insurance Company (Companies) all information required concerning my (our) dental care. I herby assign to Barr Family Dentistry, all payments to which I may be entitled for dental expenses, and do hereby direct that payment for such expenses be paid directly to Barr Family Dentistry.
POHDVH TSH NDPH WR SLJQ
Signature of Patient or Legal Guardian
DATE
/
Month
/
Day
Year
Date
PRINT NAME
PATIENT MEDICAL HISTORY
PATIENT MEDICAL HISTORY
*
PATIENT NAME:
PHYSICIAN NAME:
PHYSICIAN NAME:
*
Phone:
HAVE YOU BEENTREATED FOR THE FOLLOWING? PLEASE MARK YES OR NO
HAVE YOU BEENTREATED FOR THE FOLLOWING? PLEASE MARK YES OR NO
*
AIDS / HIV
No
Yes
No
Are you allergic to or had any reactions to the following?
HAVE YOU BEENTREATED FOR THE FOLLOWING? PLEASE MARK YES OR NO
No
Are you allergic to or had any reactions to the following?
Yes
No
Anemia
Local Anesthetics
Artificial Joints / Implants
Yes
No
Yes
Yes
No
Penicillin
Yes
No
Yes
Yes
No
Erythromycin
Yes
Yes
No
Artificial Heart Valve
Yes
Yes
No
Codeine
Yes
Yes
No
If yes, please list type / date:
/
Month
/
Day
Year
Date
If yes, please list type / date:
/
Month
/
Day
Year
Date
Anti-Inflammatory
Yes
Yes
No
Back / Neck Injury
Yes
Yes
No
Acetaminophen
Yes
Yes
No
Asthma
Yes
Yes
No
Others, please list:
Cancer
Yes
Yes
No
If yes, please list type / date:
/
Month
/
Day
Year
Date
Chemical Dependency
Yes
Yes
No
Chemotherapy / Radiation
Do you use tobacco?
Diabetes
If yes Type I Type II
If yes Type I Type II
Diabetes
Yes
No
Yes
Yes
No
If yes, what type and how often?
Do you use marijuana?
Yes
No
Emphysema
Yes
Yes
No
If yes, how often?
Epilepsy
Have you ever had prolonged bleeding following an extraction?
Fainting / Dizziness
Yes
No
Yes
Yes
No
No
Yes
No
Yes
Yes
No
Headaches
Yes
Yes
No
Are you currently taking any blood thinners?
Heart Attack
Yes
Yes
No
Are you currently, or have you ever taken Bisphosphonates?
Yes
No
If yes, when?
Heart Disease
Yes
Yes
Yes
No
Do you have any sores or lumps in or near your mouth?
Yes
No
Heart Murmur
Yes
Yes
No
Yes
Yes
No
Heart Problems
Yes
Yes
No
Do you clench or grind your teeth?
Yes
Yes
No
Hepatitis
If yes, type: A B C
If yes, type: A B C
If yes, type: A B C
Yes
Yes
No
Do your gums bleed while flossing?
Yes
Yes
No
Do you wear dentures or partials?
Tuberculosis
If yes, please list date of initial placement:
/
Month
/
Day
Year
Date
Herpes / Cold Sore / Blister / Fever
Yes
No
Yes
Yes
No
Are you under any medical treatment now?
Are you interested in improving your smile with teeth whitening? Yes No
Are you interested in improving your smile with teeth whitening? Yes No
Hemophilia / Bleeding Disorder
Yes
Yes
No
MEDICATION
MEDICATION
TREATMENT
TREATMENT
TREATMENT
High Blood Pressure
Yes
Yes
No
High Cholesterol
Yes
Yes
No
Stroke
No
If yes, when:
Kidney Disease
Thyroid Problems
Yes
Yes
No
Yes
Yes
No
IF YOU HAVE ADDITIONAL MEDICATIONS, PLEASE BRING LIST TO APPOINTMENT
IF YOU HAVE ADDITIONAL MEDICATIONS, PLEASE BRING LIST TO APPOINTMENT
Liver Disease
Yes
No
Yes
Yes
No
Low Blood Pressure
Last Blood Pressure:
Date Taken:
/
Month
/
Day
Year
Date
Mitral Valve Prolapse
Yes
No
Yes
Yes
No
WOMEN: Are your pregnant?
Yes
No
WOMEN: Are your pregnant?
Scarlet Fever
Psychiatric Care
Yes
No
Yes
Yes
No
If yes, please list due date:
/
Month
/
Day
Year
Date
Arthritis, Rheumatism
Yes
Yes
No
Are you taking any oral contraceptives?
Yes
Yes
No
Yes
Yes
No
Blood Disease
Are you nursing?
Other, please list:
Please list the reason for your visit today:
Please list the reason for your visit today:
Please list your long term dental goals:
What is the name of your previous dentist / location?
AUTHORIZATION AND RELEASE
I certify that I have read and understand the above information to the best of my knowledge. I authorize the dentist to release any information including the
diagnosis and results of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and / or health
practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand
that my dental insurance carrier may pay less than the actual amount billed for services. I agree to be responsible for payment of all services rendered on my behalf
or my dependents.
Please Type Name for Signature:
Signature of Patient (or Parent if Minor)
Date
/
Month
/
Day
Year
Date
REVIEWED BY:
UPLOADED:
UPLOADED: ___________ UPLOADED:
Review and Submit
Should be Empty: