Adult Paperwork

PATIENT INFORMATION

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed alowances for certain procedures, and others pay a percentage of the charge. It is your responsibility ot pay any deductible amount, co-insurance, or any other balance not paid for by your insurance company. In order to control cost of billing, we request that your co-payment be paid at the conclusion of each visit. Insurance Authorization and Assignment: I hereby authorize Dr. Ty Barkley and Associates to furnish information to my insurance company concerning my dental condition and treatments and I hereby assign to the dentist al payments for dental services rendered to myself and for my dependents. I understand that I am responsible for any amount not covered by insurance.

HEALTH HISTORY

Please answer each question. Check yes or no. If doubt, leave blank.

I give my consent to radiographic examination (x-rays) for the purpose of dental diagnosis. I give my consent to use local anesthesia, nitrous oxide analgesia, and relaxants for the purpose of having the necessary dental treatment completed. I understand that I am responsible for all costs of dental treatment. To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or change in my medication, I will inform the dentist at the next appointment.