All Patient Forms

New Patient Information

Please complete form to the best of your ability.
Welcome! Thank you for selecting our office. It is our goal to provide for your dental needs as thoroughly and efficiently as possible. Please read and complete the following materials. If you have any questions, don't hesitate to ask.

This entire form is HIPAA Complaint and secure.
Today's date*

MonthDayYear
Date
Patient's legal name:*

First NameLast Name
Name you prefer to be called:*
Gender identification:
Preferred pronoun:*

He/HimShe/HerThey/Them
Birthdate (month / day / year):*

MonthDayYear
Date
Current age:*
Patient's address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN#:*
Status:*
Home phone:
Cell phone:
Work phone:
Preferred phone to contact during business hours:*

CellHomeWork
Email address:*
example@example.com
Emergency contact full name:*
Emergency contact phone number:*
Emergency contact relationship to patient:*
Patient's employer:
Occupation:
Employer's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PRIMARY INSURANCE INFORMATION

Please bring your insurance card to your appointment.
Subscriber's name:*
Subscriber's employer:*
Insurance company name:*
SECONDARY INSURANCE INFORMATION

If none, leave blank.
Subscriber's name:
Subscriber's employer:
Insurance company name:
MINOR PATIENTS ONLY

If adult, leave blank.
Who is responsible for the account:
Relationship(s) to minor:
MEDICAL INFORMATION RELEASE FORM (HIPAA Release Form)

I authorize the office of Tyler Link & Barnes to release any information including the diagnosis and treatment or examination rendered to me or my dependent/child during the period of such dental care to third party payers (insurance company) and/or other health practitioners. Email correspondence will be in encrypted format.
In addition, authorization to disclose appointment times, diagnosis, records, insurance claims, and account and treatment information is given to:*

Information is not to be released to anyoneInformation may be released to person indicated below
Info may be released to:

First NameLast Name
Relationship to patient:
This Release of Information will remain in effect until terminated by me in writing.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received a copy of the Statement of Privacy for the office of Tyler Link & Barnes. The statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office healthcare operations. Also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the office. Tyler Link & Barnes reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If Privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

GENERAL CONSENT TO PERFORM DENTISTRY

I hereby authorize any of the doctors and dental auxiliaries at this facility to proceed with and perform dental procedures and treatments as have been explained to me for myself or dependent. I understand that treatment can only be estimated and subject to modification depending on unforeseen or un-diagnosable circumstances that may arise during the course of treatment.
I hereby authorize any of the doctors and dental auxiliaries at this facility to proceed with and perform dental procedures and treatments as have been explained to me for myself or dependent. I understand that treatment can only be estimated and subject to modification depending on unforeseen or un-diagnosable circumstances that may arise during the course of treatment.
OFFICE POLICY

Late Arrival: Patients are asked to arrive at their appointments before their scheduled appointment time. A grace period of 10 minutes will be permitted for unforeseen delays that patients may encounter while traveling to the office for their scheduled appointment. If a patient arrives more than 10 minutes late for their appointment, the patient will be given the option of either being seen that day as a walk-in, if the schedule permits, or rescheduled for a later date. This process will ensure patients who do arrive on time are seen in a timely manner.

Missed Appointments: We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable. However, advance notice allows us to fulfill scheduling needs and keeps the clinic operating at its most efficient level. Due to our one-on-one treatments, missed appointments are a significant inconvenience to your dentist, the office, and other patients. This policy is in place out of respect for all of us, including you. A “No Show” is a patient who fails to appear for a scheduled appointment without providing a 24-hour cancellation notice. Cancellations with less than 24-hour notice are difficult to fill. By giving last minute notice or no notice at all, you prevent someone else from being able to schedule into that time slot. In the event of three (3) documented “No Shows,” the patient may be subject to dismissal from the practice.

Diagnostic Guidelines: An exam by a licensed dentist in this office is recommended every six (6) months. Additionally routine diagnostic radiographs are updated based on the American Dental Associations guidelines (full mouth series every 3-5 years and bitewings every 1-2 years). Dental radiographs and examinations are necessary for diagnosing and treatment planning of dental conditions.
FINANCIAL POLICY

Payments: For your convenience, we accept cash, checks, and credit cards (Visa, MasterCard, Discover, and American Express). A fee of $30 will be added to your account for any checks returned by your bank. Unless a payment plan has been approved in writing, the balance on your statement is due and payable when a statement is issued, and is overdue if not paid by thirty (30) days after statement date.

Finance charges: A finance charge will be imposed on each procedure of an account which has not been paid within 60 days of the time the item was added to the account. The finance charge will be computed at a 1.5% monthly finance/interest charge. If the account becomes past due, we will take necessary steps to collect the remaining balance, which may negatively impact credit history and/or lead to the dismissal from our office.

Divorce: In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a dependent/child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.

Patients with insurance coverage: Insurance benefits are determined by your employer, not the dental provider. Insurance is not a guarantee of payment; it may not cover all your costs. Your insurance policy is a contract between you, your employer, and your insurance company. Payment to Tyler Link & Barnes is ultimately your responsibility. You agree to authorize assignment of insurance rights and benefits directly to the provider for any services rendered. As a courtesy we will file your dental claim for you, but we do not accept responsibility for the outcome of the transaction. By having our office process your insurance forms, it is important to understand that this does not eliminate your financial obligation for your treatment. Our practice will not enter into a dispute with your insurance company over a claim. We will cooperate with documentation requests from your insurance company, but it is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company to our practice. If your insurance company has not paid your claim within 60 days after the date of service, the full amount is due and payable by you. We will promptly refund to you any insurance payments we receive if you have already paid the balance on your account. It is your responsibility to inform us of any changes in your insurance coverage.

Secondary Insurance Policies: Even if you have dual coverage (which is possible when you and your spouse both have insurance) there may still be a portion that is your responsibility. We file claims to many different insurance companies, and it is impossible for us to know what your insurance provider deems as a non-covered service or a duplicating procedure.

Delta Dental Wellness Insurance: In order to provide a continued high level of care to our patients, we will not be accepting any new patients with Delta Dental Wellness Insurance. New patient status also applies to previous patients with an inactive status (those patients who have not been seen in our office in over 24 months). If a new patient has or switches to Delta Dental Wellness Insurance, they will be seen on an emergency basis only for 30 days. During that 30-day window before termination, we encourage the patient to reach out to their insurance to find another office who can provide the services needed. The office will forward any records to the new dental care provider upon request. This policy will be effective March 1, 2023 and will apply to all new and inactive patients from that date forward.

Appointments involving lab work: Procedures involving lab work may require a 50% down payment, the remaining balance must be paid before final delivery.
This is an agreement between Tyler Link & Barnes and the patient named on this form. By executing this agreement, you consent to treatment by Tyler Link & Barnes and agree to pay for all services that are received. Once you have signed this agreement, you agree to all terms and conditions contained herin and the agreement will be in full force and effect.
PATIENT'S NAME:*
RESPONSIBLE PARTY (If patient is a minor):
PATIENT SIGNATURE for Financial Responsibility: (Legal guardian/parent to sign, if patient is a minor)*

Clear
DENTAL HISTORY
Please state the reason for today's visit*
Date of last visit to a dentist*

MonthDayYear
Date
Date of last dental cleaning*

MonthDayYear
Date
Do you know the date of your last full mouth x-rays?*

NoYes
If yes, what was the date of your last full mouth x-rays? (If no, leave blank)

MonthDayYear
Date
Previous Dental Office/Dentist
Address
Phone
How often do you have dental visits/examinations/cleanings?
How often do you brush?*

3+ times per day2 times per day1 time per dayWeeklySeldom
How often do you floss?*

1+ times per day2-6 times per week1-6 times per monthSeldomNever
Do you use other dental aids?

ToothpicksSonicareWaterpikFloss aidsElectric brush
Are you happy with the appearance of your teeth and smile?*

YesNo
If no, please describe:
Do you have any dental problems at this time?*

YesNo
If yes, please describe:
Have you had any of the following? (Please check the box to indicate "YES". Leave blank if "NO")
Please describe any "YES" answers from above.
Do you do any of the following? (Please check the box to indicate "YES". Leave blank if "NO")
Please describe any "YES" answers from above.
MEDICAL HISTORY
Physician's name/clinic*
City*
Phone*
Date of last physical/medical exam: (month/year)*

MonthDayYear
Date
Have you been a patient in a hospital in the past 5 years?*

YesNo
If yes, for what?
Have you had any allergic reactions (rash, hives, anaphylaxis) or adverse reactions (nausea, upset stomach, dizziness) to any medications or substances?*

YesNo
If yes, please describe substance and reaction:
Have you ever been told to take antibiotic pre-medication before dental treatment?*

YesNo
If yes, for what?
Do you currently or have you in the past used tobacco/nicotine?*

YesNo
If yes, type, amount, and years:
Women: Are you pregnant?

YesNo
If yes, how many weeks along are you?
Women: Are you breastfeeding?

YesNo
Please indicate any condition you have had in the past or currently have: (Please check the box to indicate "YES". Leave blank if "NO")
Do you have any disease, problem, or condition not listed? If yes, please describe. (If no, leave blank.)
Please list current prescription medications, over-the-counter medications, vitamins, herbals, and/or supplements: (Please be sure to click "Save Row" for each medication entered)
Pharmacy of choice:*
Pharmacy phone number:*
Please enter a valid phone number.
I have answered this health history to the best of my knowledge.
Signature (Parent signature if minor)*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

New Patient Information

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

MINOR PATIENTS ONLY

DENTAL HISTORY

MEDICAL HISTORY