General Dentistry Neuromuscular Dentistry Cosmetic Dentistry Sleep Medicine
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1 PO Box 297 Hedgesville, WV KenBarneydds.com General Dentistry Neuromuscular Dentistry Cosmetic Dentistry Sleep Medicine WELCOME TO OUR PRACTICE Welcome to the office of Dr. Kenneth C. Barney and his team. We are pleased you have chosen our office for your dental care. Our practice is dedicated to providing superior dental care and we are proud of our dedication to our patients. Our goal is to help you feel and look your best through excellent dental care. You will find that our approach to dental care aims for excellent dental health, comfort, and satisfied patients. Our office is equipped with state of the art equipment, computers and instrumentation. YOUR FIRST VISIT On your first visit, a permanent record will be established. You will be asked to complete a brief health history questionnaire. Necessary records will be taken, if needed, including radiographs, photographs, and study models of all teeth in order that the Doctor can best give a full and proper assessment. We will then discuss potential treatment options and fees, and answer any questions you may have. APPOINTMENTS Patients are seen by appointments. We value our patients time and therefore strive to stay on our schedule. Please assist us by being on time for your appointments. IF we are seriously delayed, we will try to notify you. If you are unable to keep your appointment or are going to be late, please call our office as soon as possible. This courtesy allows us to be of service to other patients in need. In order to avoid a cancellation fee, 24 hours advanced notice is required to make a change in scheduled appointments during regular business days (Mon-Thurs.) PATIENT CONCERNS Please feel free to call our office if you have any questions regarding your treatment, appointments, or prescriptions. Our staff is specially trained to answer your questions. If you need to speak with Dr. Barney personally, our office staff will arrange for him to return your call as soon as conditions permit. UNDERSTANDING COSTS Excellent dental care is one of the best investments you will ever make. Dental conditions vary in complexity and severity, and fees reflect these differences. Fees for services rendered in our office are based on the Doctor s skill, knowledge, judgment, experience and expertise. At the time of scheduling your next treatment, our office staff will discuss your financial arrangements in detail. Our office chooses to be a private fee for service practice. Payment is due when services are rendered. Please do not ask us to bill you for your appointment. Financial 1
2 options are available through third party financing (Care Credit is the financial institution we work with). Our office accepts Master Card, Visa, Discover, cash or personal check also. INSURANCE Our office will process your dental insurance as a courtesy. We accept dental insurance assignments providing the insurance will send payment to our office and with the understanding that any uninsured portion that is not covered by your dental plan is to be paid by you at the time of service. Your dental insurance coverage is based on the policy or contract your employer purchased. Depending on your specific policy, your dental insurance plan may not cover fully our dental fees for services rendered. Dr. Barney does not participate with any insurance companies as he does not want to have the insurance company dictate the type of care you receive. Our office is ultimately working for you, not the insurance company. Please remember the ultimate financial responsibility is yours. SPECIALIST REFERRALS As a general dental practice we will be in contact with the doctors and health care providers who referred you to our office to reassure the continuity of treatment. At times, the Doctor will also recommend our patients consult specialist to help assist in needed specialty care and services that are appropriate in providing the best quality care and outcome. NEW PATIENT REFERRALS Your kind referral is the best compliment we could ever receive! We are always happy to accept new patients. We welcome your referrals of friends, co-workers, family members and relatives. We value your trust and confidence in us and will take special care of the people you refer. Thank-You!! ABOUT THE STAFF Dr. Barney has chosen a qualified team to assist him in treating and caring for each one of his patients in a quality, individualized manner. His front office personnel are experienced, skilled, trained and qualified to meet your needs and concerns. All team members have taken extensive continuing education to enhance their skills to better serve you. OUR TEAM MEMBERS: Sonie Shelly Thank you again for giving us the opportunity to serve you. We know you will find our office to be pleasant and professional every time you visit us. We look forward to seeing yo 2
3 Date: WELCOME KENNETH C. BARNEY, D.D.S., FELLOW LVI OFFICE OF DENTAL EXCELLENCE LVI Fellow PATIENT INFORMATION NAME ( ) Married ( ) Single ( ) Other Male ( ) Female ( ) PREFERRED Name ADDRESS BIRTH DATE SS# CONTACT NUMBERS (Check where you would prefer we call or contact you) ( ) Home Phone ADDRESS ( ) Work Phone ( ) Cell Phone PLACE OF EMPLOYMENT/SCHOOL Whom may we thank for referring you to our office? FAMILY INFORMATION HUSBAND (or father) WIFE (or mother) Last First M Last First M Street City, State Zip Street City, State Zip Home # Work # Home # Work # Birthdate SS# Birthdate SS# Employer Employer IN CASE OF EMERGENCY Outside of immediate family or household Name Address Phone Number ACCOUNT/PAYMENT Person responsible for account Signature Preferred Method of Payment ( ) Cash or Check ( ) Credit Card 3
4 OFFICE OF DENTAL EXCELLENCE ( ) Alternative Billing source (ask KENNETH C. BARNEY, D.D.S. Dental History Do you have a specific dental problem? Yes No Do you have regular dental care? Last Visit Yes No Do you think you have decay, gum disease, or jaw problems? Yes No Do your gums ever bleed? Yes No Do you Floss? How Often Yes No Are you interested in improving your smile? Yes No Would you like to have whiter teeth? Yes No Does food catch between your teeth? Yes No Do you ever have clicking, popping or discomfort in your jaw joint? Yes No Do you clinch or grind your teeth? Yes No Have you ever had a bad dental experience? Yes No Do you smoke or chew tobacco? Yes No Name of previous dentist and location (optional) Last date of X-rays: Bitewings Panorex Full series SYMPTOMS Check all that apply ( ) Headaches ( ) Facial Pain ( ) TMJ Pain ( ) Tender sensitive teeth ( ) TMJ Noise ( ) Difficulty Chewing ( ) Limited Opening ( ) Neck Pain ( ) Ear Congestion ( ) Postural Problems ( ) Dizziness ( ) Tingling/numbness in fingers ( ) Ringing in the ears ( ) Hot and Cold sensitivity ( ) Difficulty Swallowing ( ) Nervousness ( ) Loose teeth ( ) Insomnia ( ) Clenching/Bruxing ( ) Trigeminal Neuralgia ( ) Bell s Palsy ( ) Back Pain MEDICAL HISTORY Circle all that apply Heart Murmur Lung Disease Tuberculosis Kidney Disease Angina/Chest Pain Allergies Artificial Heart Valve Thyroid Disease Heart Attack/failure Sinus problems Heart Pace maker Cold sores/fever Blisters Congenital Heart Disorder Asthma Blood Disease Cancer Mitral Valve Prolapse Snoring Blood Pressure Problem OTHER Rheumatic Fever Liver Disease Excessive Bleeding Artificial Joints Mental Disorders Hepatitis A,B, or C Diabetes Heart Disease Stroke Epilepsy None of the Above Are you under a physician s care? If so, Why Name Are you taking ANY medications? Please list: Are you ALLERGIC to any medications? Penicillin Codeine Sulpha Latex Metals Acrylic Are you pregnant or trying? Contraceptives? Have you been in a serious accident or hospitalization? Any other information you would like us to know? To the best of my knowledge, all of the preceding answers and information provided are true and correct, If I every have any change in my health history, I will inform the doctor at the next appointment. 4
5 Signature Date OFFICE OF DENTAL EXCELLENCE KENNETH C BARNEY, D.D.S. EMPLOYMENT INFORMATION The following is for the patient the person responsible for payment Employer Name Occupation Address _ Phone INSURANCE INFORMATION Primary Name of Insured is insured a patient yes no Birthdate ID# Group# Address Employer Address Patient s relationship to insured self spouse child Insurance Plan Name and Address Insurance Phone Secondary Name of Insured is insured a patient yes no Birthdate ID# Group# Address Employer Address Patient s relationship to insured self spouse child Insurance Plan Name and Address Insurance Phone 5
6 Office of Dental Excellence Kenneth C. Barney, D.D.S. CONSENT FOR SERVICES Please read carefully As a condition of your treatment by this office, this practice requires reimbursement from the patient for the costs incurred in their care. All dental services performed must be paid in full at the time services are rendered. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will extend the courtesy of preparing the insurance forms. We will assist in making collections from insurance companies and will credit any such collections to the patient s account if the insurance company sends benefits to the doctor. Any portion not paid by the insurance is the responsibility of the patient and is due in full at the time services are rendered. Ultimately, the amount paid by insurance is determined by the insurance carrier based on information that may not be disclosed to our office. Insurance and patient portions are estimates provided as a courtesy. In the event that your insurance carrier pays less than estimated, the unpaid balance is due from the patient. Account balances that exceed 30 days will receive a service charge of 1 ½% per month (18% per annum) on the unpaid balance. I understand that the fee estimate listed for dental care can only be extended for a period of six month from the date of the patient examination. I have read the above conditions of treatment and agree to their content. Signature Date Relationship Insurance Patients: Please read and sign below I authorize release of information to the previously named insurance company/companies. Signature of insured person I authorize payment directly to Dr. Barney of the Group Insurance Benefits otherwise payable to me. Signature of insured person Thank you for taking the time to complete our form. This will help us to be of greater service to you. 6
Patient Information. If Patient is child, Parent s Name. City State Zip Cell# SS# of Patient Driver s License #
Patient Information Patient Name Date of Birth If Patient is child, Parent s Name Street Address Male or Female City State Zip Cell# Home# Work# Name of Employer Email Address SS# of Patient Driver s License
How did you hear about our office?
PATIENT INFORMATION Patient's name Preferred name Male Female If minor, responsible party name Mailing address City State Zip Social Security Number Birth date Home phone Work phone Cell phone Email Employer
Alldent Dental Center Patient Registration
Patient Registration DATE Patient Name Age Address Home Phone Cell City State Zip Email Social Security # Date of Birth Sex: M F Single Married Divorced Widowed Separated Employed by Occupation Business
Guardian/Patient Name. Family Dental Care NC. 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 SIGNATURE ON FILE
Guardian/Patient Name Family Dental Care NC 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 Date/Initial SIGNATURE ON FILE I authorize use of this form on all my insurance submissions.
NEW PATIENT REGISTRATION
Welcome! NEW PATIENT REGISTRATION Thank you for choosing. We are committed to providing every adult and child with the highest quality oral healthcare in the most gentle, efficient manner possible. Remember,
WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
HIRSHFIELD DENTAL CARE 50 NORTH ST. MEDFIELD, MA 02052 Today s date WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
Date. Initial. Initial. Minor ADDRESS. Cash ADDRESS
PATIENT NAME IF CHILD: PARENT'S NAME HOW DO YOU WISH TO BE ADDRESSED Single Married RESIDENCE - STREET Separated Divorced Widowed CITY STATE ZIP TELEPHONE: RES. EMAIL ADDRESS PATIENT/PARENT EMPLOYED BY
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Name: Phone: Ins. Co: Group #: ID# Phone #: Name of Insured: Relationship to patient: SS#: / / DOB: / / Employer: Phone:
PATIENT INFORMATION Thank you for choosing us as your dental care provider. We look forward to caring for you! Patient Information: Patient Name (First Middle Initial Last): DOB: / / SS#: / / Driver s
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CONSENT FOR TREATMENT
PATIENT INFORMATION PERSON FINANCIALLY RESPONSIBLE LAST NAME FIRST M.I. NAME RELATIONSHIP TO PATIENT PREFERS TO BE CALLED BY MALE FEMALE BIRTH DATE SOCIAL SECURITY NO. BIRTH DATE SOCIAL SECURITY NO. ADDRESS
PATIENT REGISTRATION. First Name: Middle Initial: Last Name: Home Phone: Work Phone:
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IDENTIFICATION PATIENT REGISTRATION Today's Date PLEASE PRINT CLEARLY AND FILL IN ALL THE SPACES BELOW Patient Name (Last, First, Middle Initial): Date of Birth Social Security # Mailing Address City State
Trinity Dental Phone: 260-582-2607 900 S. Main Street, Kendallville, IN 46755 [email protected] PATIENT INFORMATION
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Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
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Medical History Questionnaire
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