Form Logo
Patient Information
Dental Insurance Information
Primary Dental Insurance
Secondary Dental Insurance
Financial Policy
Thank you for choosing Barrett Family Dental for your dental care. We are here to help you in any way we can, so please, if you have any questions or concerns about your dental care, do not hesistate to ask us. Our goal is to provide you with the best possible oral health and give you the tools and education to help you achieve your goals.

We believe that in order to do this, insurance companies should not dictate the quality of treatment our patient’s receive. As a courtesy, we will file claims to your insurance and inform you of their estimated portion to maximize the benefits due to you. We are happy to provide you with an estimate of insurance coverage. We cannot guarantee payment from your insurance company, as your coverage is a contract between you and your insurance.

Payment Options
We offer multiple payment options in order to help you in any way:
- Cash only patients will receive a discount of 5%
- Visa, Mastercard, Discover, and American Express are all accepted.
- CareCredit is available as a monthly finance option, must be approved, please ask for details.

Cancelation Policy
Appointment times are arranged specifically for you. If for any reason, you should need to change your appointment, there will be no charge, provided you give us a minimum 48 hour (2 business days) notice. A $50 charge per hour will be added to all patient accounts who do not give proper notice. Please help us to serve you better by keeping your scheduled appointments.

Late Fee Assessment
As a courtesy, 90 days will be given to finish making payments for the patient portion of any treatment rendered. After the 90 days, interest will begin to accrue at 1.5% per month until the balance is cleared.

By signing below, you are stating you have read and understand our financial policy.
HIPAA Acknowledgement and Consent Form
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

- Conduct, plan and direct my treatment and follow‐up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly.

- Obtain payment from designated third‐party payers.

- Conduct normal health care operations such as quality assessments or evaluations, and physician certifications.

I have been informed by you of the Notice of Privacy Practices; containing a more complete description of the uses and disclosures of my health information (available in office in print form or on the office website I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address(es) below to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if the organization does agree, then it is bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent.
Health History Form
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
Dental Information
Medical Information
Medical Information
NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.