DENTAL HISTORYReason for today’s visit: __________________________________________________________________________________Who is your current general dentist?______________________________________Tel. (______) _______________________How long have you been under the care of your current dentist? _________________________________________________Previous dental care has been: Regular, every_______months IrregularWhen was your last dental exam and/or hygiene appointment? __________________________________________________How often do you brush your teeth?__________________________ How often do you floss? _________________________Please, indicate any of the following problems by checking off the corresponding box:Are you in pain or having any discomfort in your mouth? Yes No If yes, please specify ____________________________Do you have fear or anxiety towards dental procedures? Yes NoDo you have red, swollen, or bleeding gums? Yes NoDo you have recurrent blisters or sores in or around your mouth? Yes NoDo you have tooth sensitivity to cold, hot, or sweets? Yes NoDoes food get frequently caught between your teeth? Yes NoDo you have dry mouth? Yes NoDo you have TMJ problems, discomfort, clicking, or popping of the jaws? Yes NoHave you had any head, neck or jaw injuries? Yes N

PATIENT INFORMATION TODAY’S DATE:_________________________ Mr. Mrs. Ms. Dr.First name:_____________________________M.I._____ Last name:______________I like to be called: __________________Sex: M F Birth date:________________ SS#:___________________ Driver’s License #: _____________________Marital Status: Married Single Divorced Widow Stable union Spouse’s name : __________________________Mailing address:_______________________________City____________________________State_______Zip ____________Employer:___________________________________________________________ Occupation: ________________________Cell (_____)_______________________Home (_____)_______________________Work (_____)_______________________Preferred phone for contact: Cell Home Work Email: ___________________________________________Whom may we thank for referring you to our practice? _________________________________________________________PERSON TO CONTACT IN AN EMERGENCYName____________________________________________ Tel. (_____)_________________Relation ___________________

DENTAL INSURANCE INFORMATIONInsurance Co. name ___________________________ Insurance Co. Ph. # _________________ Group # _________________Subscriber’s name ____________________________________ Subscriber’s ID # ____________________________________Relationship to patient __________________ Subscriber’s DOB __________________ Subscriber’s SS# __________________Street address: (if different from patient’s)__________________________City________________State_____Zip __________Subscriber’s employer ___________________________________________________________________________________MEDICAL INSURANCE INFORMATIONInsurance Co. name ___________________________ Insurance Co. Ph. # _________________ Group # _________________Subscriber’s name ____________________________________ Subscriber’s ID # ____________________________________Relationship to patient __________________ Subscriber’s DOB __________________ Subscriber’s SS# __________________Street address: (if different from patient’s)__________________________City________________State_____Zip __________Secondary medical insurance (if applicable) ____________________________Insurance Co.’s Ph #______________________Group #________________ Subscriber’s name ______________________________ Relationship to patient ______________Subscriber’s ID# _____________

Bruce M. BarBash, DDsMaxillofacial ProsthoDontist

Written Financial policy

Thank you for choosing Bruce Barbash, D.D.S. Our primary mission is to deliver the best and most

comprehensive Dental/Medical care available. An important part of the mission is making the cost of

optimal care as easy and manageable for our patients as possible by offering several payment options.

PAYMENT OPTIONS You can choose from:

– Cash, Check, Money order, Visa, MasterCard, American Express or Discover Card

– NO INTEREST1 Payment Plans from CareCredit and Lending Club

• Allows you to pay over time with NO INTEREST1

• Convenient, low monthly payment plans also available (Subject to credit approval) • No annual fees or pre-payment penalties

Patient is responsible for payment at the time of visit. We will file your insurance as a courtesy. Our office

does not accept insurance as a form of payment. I understand that Bruce Barbash, DDS is an out of

network provider for my insurance company. I understand that all of the services performed may not be

covered by my insurance contract. I understand that my insurance contract may not pay 100% of Dr.

Bruce Barbash’s submitted fees.

Payment for all dental procedures is due at the time of service.

We are not taking responsibility for you or us receiving payment from your insurance company.

We will mail or electronically file your claim form to the insurance company following services rendered.

We will also assist you in filing the claim by sending any necessary documents and/or narratives.

We will not follow up with any dental insurance claims unless the insurance company requests additional information.

Our office does not guarantee that your insurance company will pay for treatment that you receive in our office.

Although we are willing to complete insurance forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the transaction. Completing insurance forms is a courtesy we extend to you in an effort to maximize your insurance reimbursement.

Medical services under $2,500 are due at the time services are rendered. Medical services greater than

$2,500 require a 50-70% deposit, at the time services are rendered. I agree to pay the remainder of the

fee not covered by my insurance to Dr. Bruce Barbash.

It is important to understand that the contract regarding your Dental and Medical benefits is

between you, your employer, and your insurance company.

Patient, Parent or Guardian Signature Date

Patient Name (Please Print)

1-Offered for services over $2,000. If paid within the promotional period. Otherwise, interest assessed from purchase date.