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New Patients Must Fill Out the Form Below

We are thrilled that you’d like to join our family of patients!

Please fill out the form below in its entirety. By submitting the form to our office, you agree that all “Digital Signature” fields stand for your official signature.

Our Appointment Coordinator will contact you to set up your first appointment.

Patient Resources

Our Office is In-Network for Delta Dental

At this time, we are only in-network with Delta Dental, and we are not accepting new Medicaid patients.

We prefer to being with an overall exam, a full series of images, and a thorough cleaning by our hygiene department. However, if you are a new patient to the practice and have a dental emergency, our policy is as follows.

  1. All forms must be filled out online, prior to the appointment.
  2. The first visit must be paid in full on the day the services are rendered. We accept cash, VISA, MasterCard, Discover and CareCredit.
  3. If the patient has insurance, we will gladly provide the insurance form for the patient to file.
  4. A follow up appointment must be made for an exam and cleaning. If this appointment is not kept, the patient will be dismissed from the practice.
New Patient Forms
  • First Name*
  • Last Name*
  • Last Dental Exam*
  • Street Address*
  • City, State, Zip*
  • Home Phone*
  • Cell Phone*
  • Work Phone*
  • Email*
  • DOB*
  • Marital Status*
  • Do you have dental insurance?*
  • Name of Primary Insured*
  • Primary Insured DOB*
  • Primary Insured Employer Name and Address*
  • Primary Insured Home Phone*
  • Primary Insured Work Phone*
  • Name of Secondary Insured*
  • Secondary Insured DOB*
  • Secondary Insured Employer Name and Address*
  • Secondary Insured Home Phone*
  • Secondary Insured Work Phone*
  • Responsible Party*
  • Home Phone*
  • Work Phone*
  • Physician's Name*
  • Physician's Phone*
  • Pharmacy*
  • Pharmacy Phone*
  • Previous Dentist Name*
  • Previous Dentist Phone*
  • Date of Last Dental Images (X-rays)*
  • Who referred you to our office?*
  • Sex*
  • Do you smoke or use tobacco?*
  • If female: Are you taking Birth Control Pills?*
  • If female: Are you pregnant?*
  • If pregnant, how many weeks?*
  • Are you nursing?*
  • Condition: Please check all that apply.*
  • Allergies: Please check all that apply.*
  • Do you have any allergies not listed above?*further details
  • Please list all medications including non-prescription drugs and herbal supplements.*
  • Please list recent hospitalizations.*
  • Have you ever had joint replacement?*
  • If yes, which joint and date of replacement?*
  • Do you currently take antibiotics prior to dental treament?*
  • If yes, for what condition?*
  • If yes, please give the name and dosage of the antibiotic.*
  • Is there any disease, conditions, or problems that you think this office should know about that is not covered above?*
  • Additional Comments*
  • Digital Signature*
  • Digital Guardian Signature (if under 18)*full name here
  • Consent for Dental Treatment
  • Patient Name*
  • I request and authorize Dr. Karen Barwick and/or associates or assistants of her choice to perform needed treatments/procedure(s):

    I further request and authorize the taking of oral dental Images and the use of such anesthetics as may be considered necessary and/or advisable by the doctor responsible for my/the patient’s treatment.

    I have had explained to me, and I have had sufficient opportunity to discuss my/ the patient’s dental condition/problem(s), the planned procedures and treatment, and the benefits to be reasonably expected from this treatment, compared with alternative approaches and/or no treatment.

    The usual and most frequent risk or complications occurring from the planned treatment and procedures also have been explained to me. These risks include, but are not limited to, the possibility of pain or discomfort during the following treatment, swelling, infection, bleeding, injury to adjacent teeth and surrounding tissue, development of a transient or permanent temporomandubular joint (TMJ) disorder, opening of or displacement of a tooth or portion thereof into the sinus (a normal cavity situated about upper teeth) or other anatomic location requiring additional surgery to close the opening or recover the tooth structure, temporary or permanent numbness, and allergic reactions.

    I understand that during the course of my/the patient’s dental treatment something unexpected may arise that may necessitate procedures in addition to or different from those planned. I am aware that the practice of dentistry is not an exact science, and I acknowledge that no guarantees have been made concerning the results of the treatment that I/the patient will receive.

    All of my questions have been answered to my satisfaction, and I consent to the treatment and procedures prescribed for me/the patient.

    I understand that I may revoke this consent to treatment at any time and that no further action based on this consent will be initiated except to the extent that treatment and procedures have already been performed or initiated.

    I confirm that I have read this form or it was read to me. And that all blanks were filled in and all inapplicable paragraphs, if any, were crossed out before I initial my agreement/acknowledgement below.

  • Digital Signature*
  • Authorization for Payment
  • Patient Name*
  • I hereby authorize payment directly to Karen Barwick DDS, PA & Associates of the dental benefits otherwise payable to me.

  • Digital Signature*
  • Please note: This signature is valid for two years from the submission date of this document unless revoked by me at an earlier date.
  • Authorization for Insurance Claims
  • Karen Barwick DDS, PA & Associates is authorized to provide an insurance company, claim administrator, and consulting health care professionals information concerning health care, advice, treatment or supplies provided. This information will be used for the purpose of evaluating and administrating claims for benefits.

    This authorization is valid for the term of coverage of the policy or contract.

    I know I have a right to a copy of this authorization upon request and agree that a scan/email/PDF of this authorization is as valid as the original.

  • Digital Signature*
  • Financial Policies
  • The financial policy in the office of Karen Barwick DDS, PA & Associates will be as follows;

    1. We will require payment on the date of services. If you have dental insurance please refer to section #2. On certain occasions, we will offer financing or payment plans. These plans, when pre-approved by Dr. Barwick, will be due each and every month. Any payments not received may void your payment or financing plan in our office and payment in full will be immediately due. We now accept CareCredit.

    2. We will file your insurance information and a copy of your insurance card. However, your deductible, percentage or co-pay must be paid on the date of services. We will need the employer offering the insurance, the employer’s address, plan number and the address, phone and fax numbers of the insurance company. We will also require the insured’s full name, address, social security number, date of birth, and telephone numbers. Failure to supply complete information will require payment in full on the date of services rendered. Once all insurance information is complete, we will attempt to collect from your insurance company for 60 days. If payment is not received within 60 days from the date of service, the balance in full becomes in the responsibility of the patient or guarantor. Payment must be received within 15 days following receipt of your statement.

    3. All accounts with balances greater than 60 days old will be assessed a monthly finance charge of 1.5%.

    4. Any and all accounts with balances older that 90 days may be forwarded to Credit Bureau Information System. All accounts reported to the credit bureau must be paid in full prior to resumption of treatment.

    I have read and agree to all of these financial policies.

  • Digital Signature*
  • Consent for Use and Disclosure of Health Information
  • Patient Name*
  • Address: Street, City, State and Zip*
  • Home Phone*
  • Cell Phone*
  • Work Phone*
  • Email*
  • Patient Chart Number*
  • To the Patient - Please read the following statements carefully.

    Purpose of Consent
    By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

    Notice of Privacy Practices
    You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

    We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

    You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

    HIPAA Compliance Officer
    Telephone: (336) 570-3882
    Fax: (336) 570-3583
    Address: 150 West Crescent Square Drive, Graham, NC 27253

    Right to Revoke
    You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

    I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and heath care operations.

  • Digital Signature*
  • Personal Representative (if Consent not signed by Patient)*full name here
  • Relationship to Patient*
  • YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
    Include completed Consent in the patient’s chart.


    REVOCATION OF CONSENT

    I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations.

    I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.

  • Digital Signature*