Patient Information

Marital Status

Dental insurance

Do you carry dental insurance?

Please have card available and upload

Have you been told that you need to take an antibiotic before dental visits?

How would you prefer to be reminded of appointments?


Your appointment time is reserved specifically for you, so please help us to provide the best possible care to all of our patients by notifying us as soon as possible when you cannot keep an appointment.


A no-show or late cancellation is defined as missing a scheduled appointment, without:

At least 24 hours in advance notice for a scheduled appointment.

You will be charged a $55.00 no-show fee per missed appointment.
Families or individuals who have missed appointments on 3 separate days within 12 months may be subject to dismissal from our practice.
We provide confirmation calls/texts prior to your appointment. These are a courtesy. It is ultimately your responsibility to mark your calendar for your appointments.
Additionally, it is your responsibility to provide us with accurate and up-to-date contact information.


A patient who is more than 10 minutes late to an appointment may be asked to reschedule their appointment or at least not receive all procedures planned for that time.

We are a small practice and hold firm to our schedule with respect to your valuable time. We just ask that you pay us that same respect in return.

Notice of Privacy Practices


We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 09/ 01 /2013 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment. We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.

Payment. We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.

Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.

Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts.

Required by Law. We may use or disclose your health information when we are required to do so by law.

Public Health Activities. We may disclose your health information for public health activities, including disclosures to:
• Prevent or control disease, injury or disability;
• Report child abuse or neglect;
• Report reactions to medications or problems with products or devices;
• Notify a person of a recall, repair, or replacement of products or devices;
• Notify a person who may have been exposed to a disease or condition; or
• Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

National Security. We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient.

Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.

Worker’s Compensation. We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.

Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.

Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.

Fundraising. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications.

Other Uses and Disclosures of PHI Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.

Your Health Information Rights
Access. You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure. If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.

Disclosure Accounting. With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to the additional requests.

Right to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.

Alternative Communication. You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have.

Amendment. You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.

Right to Notification of a Breach. You will receive notifications of breaches of your unsecured protected health information as required by law.

Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our Web site or by electronic mail (e-mail).

Questions and Complaints If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or if you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

Financial Agreement and Office Protocols

Patients are responsible for all charges in our office. Payment is due when services are rendered.

We will submit insurance claims immediately on your behalf for prompt processing. If applicable, I authorize and request my insurance company to pay directly to Dr. Kiley Barrett, any insurance benefits otherwise payable to me for services rendered. I verify that I am solely responsible for all charges not covered by my insurance and agree that any amounts not paid by my insurance, will be transferred to me and are due immediately. As a matter of policy, all insurance claims over 30 days will be resubmitted to your insurance company on your behalf. All account balances over 30 days are considered delinquent and are subject to a $5.00 rebilling fee per month until paid in full. In the case of default of payment, I promise to pay any legal interest due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account balance or any future accounts. There is a $40.00 service fee for any returned checks.

Your insurance company will pay only to the limits, or maximums, of its contract with you or your employer. The details to those contracts are unknown to us, as well as your individual or group benefit plan package. It is the patient’s and/or policy holder’s responsibility to be aware of any restrictions, limitations and downgrades. For example; Composite (white) fillings vs. Amalgam (silver) fillings – some insurance companies will provide an allowed amount for the composite fillings that is equal to the amount allowed for the silver fillings, and some insurance companies will not cover composite fillings at all. It is important for you to become familiar and aware of your specific plan benefits. You are responsible for any balance left unpaid by your insurance company.

To assist our patients, we offer the following methods of payment: Cash, Check, or Credit Cards. We will also accept your HSA card. For patients that qualify, we offer various payment plans through Care Credit. They offer numerous payment options that will enable you to make monthly payments. Care Credit offers a line of credit that can be used by the whole family for ongoing treatment without having to reapply. There are no upfront costs, pre-payment penalties or annual fees to our patients.

Consent for Treatment

I request and authorize Dr. Kiley Barrett, and/or staff she may appoint, to diagnose dental disease, perform or assist in the performance of dental treatment or procedures in our office. These procedures may include radiographs, models, photographs and intraoral examinations and/or restorations agreed upon by provider and patient.

It is understood that unforeseen conditions or circumstances may arise during the course of treatment; therefore I consent to and authorize the performance of any care, procedure, or treatment that Dr. Kiley Barrett deems necessary or advisable as a result of any unforeseen events, conditions, or circumstances that may arise.

I consent to the administration of any anesthetic that Dr. Kiley Barrett (or her appointees) deem necessary to provide the proper treatment and to help ensure your dental treatment be a comfortable experience. I agree to abide by any post-operative instructions given to me either verbally or in writing by Dr. Kiley Barrett or her staff and understand that if not followed, I will be responsible for work needed and cost involved to replace previous work.

I have been given the opportunity to refuse to consent to any and all treatment or procedures either verbally or in writing. I certify that I have read and understand all of the above. I acknowledge all of the proceeding answers, and the information provided is true, current and accurate. I am in agreement to all of the above, and acknowledge this by my signature.

Health history

Correct answers to the following questions will allow your dentist to treat you on a more individual basis, providing the care appropriate for your particular needs.

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

1 Are you in good health now

2 Are you now under the care of a physician

3 Have you ever been hospitalized or had a serious illness

4 Have you ever had excessive bleeding following an extraction or do cuts take longer to heal now than previously

5 (Women) Are you pregnant

6 Do you use tobacco in any form

7 Do you use alcoholic beverages more than 2 drinks per day


Tire easily, weakness

Marked weight change

Night sweats

Persistent fever


Eruptions (rash) hives

Change in skin color


Visual change



Loss of hearing

Ringing in ears


Frequent nosebleeds

Sinus problems



Nervous system






Psychiatric treatment




Asthma/hay fever

Persistent cough

Sputum production (phlegm)

Cough up bloody sputum

Difficulty breathing while laying down



Family history of diabetes

Thyroid condition/goiter


Heart / Blood vessels

Rheumatic fever

Heart murmur

Chest pain/discomfort

Heart attack/trouble

Shortness of breath

Swelling of ankles

High blood pressure

Congenital heart disease

Mitral valve prolapse

Artificial heart valve


Heart surgery


Bone / Muscles


Artificial joints/limbs

Digestive system




Change in appetite

Black, bloody or pale stools


Kidney disease

Increase in frequency of urination (night)

Burning on urination

Urethral discharge

Bloody urine

Venereal disease


Bruise easily


Blood transfusion


Radiation therapy


Tumors or growths




9. Are you ALLERGIC or have you ever experienced any reaction to the following?

Local anesthetics (e.g. novocaine)

Barbiturates/sedatives/sleeping pills

Penicillin/other antibiotics

Aspirin or codeine

Sulfa drugs

Other allergies

10. Are you taking any of the following?

Antibiotics sulfa drugs

Blood thinners

Blood pressure medication

Thyroid medicine

Cortisone / steroids

Antihistamines / allergy drugs / cold remedies


Insulin / other diabetes drugs

Recreational drugs

Digitalis / other heart medications



Other medication

If yes to any of the above, list name of medication and dosage below:

11. Is there any disease, condition or problem not listed above that you think we should know about, or is there any activity your doctor says you cannot do If so explain

12 Physicians

13 Have you ever had any serious trouble associated with previous dental treatment

14 Does dental treatment make you nervous?

15 Date of last dental visit

16 Have you ever been treated for periodontal disease (gum disease pyorrhea trench mouth)

17. Do you have or have you ever had any of the following?


Bleeding sore gums

Unpleasant taste bad breath

Burning tongue lips

Frequent blisters lips mouth

Swelling lumbs in mouth

Ortho treatments (braces)

Biting cheeks lips

Clicking pooping jaw

Difficulty opening or closing jaw


Loose teeth

Sensitive to hot

Sensitive to cold

Sensitive to sweets

Sensitive to biting

Food impaction

Clenching grinding

Shifting of teeth

Change in bite

Oral hygiene


Dental floss

Fluoride rinse


To the best of my knowledge, all of the preceding answers are true and correct.
If I have any change in my health or change in my medication, I will inform the dentist at the next appointment


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