Patient Health History Update

Fill this form out only if you have changes to your current medical history on file. Please enter your name as it currently appears on our records, then fill out ONLY the new inforamtion below. Questions? Please call 719-488-2292. 

NAME WE HAVE CURRENTLY ON FILE
NEW INFORMATION ONLY
  • Married Single
  • Female Male
  • I give Northgate Dental permission to leave messages for me on my voice mail or with persons at my residence.* Yes No
In an effort to protect you and your personal information, we will not require your Social Security number or your Drivers License number on this form. Your SS# will be required in order for us to file insurance claims on your behalf and to obtain credit in our office. A person from our office will contact you for SS# and Driver's License. This multistep process helps to protect you from identity theft.
INSURANCE CHANGES ONLY
  • I do NOT have dental insurance
    I DO have dental insurace
    I have more than one dental policy
  • New Primary Coverage

    Primary insurance coverage is the first insurance to be filed. We will need Social Security number in order to file insurance, but we will call you for that information.

  • New Secondary Insurance Coverage Secondary coverage will filed after the primary is finalized
HAVE YOU HAD A CHANGE IN YOUR HEALTH SINCE YOUR LAST VISIT?
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
FOR WOMEN ONLY
  • Yes No
  • Yes No
Are you taking or have you ever taken the following Bisphosphonate (Osteoporosis ) Medications ? 
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Consent for Communications/HIPAA:   I give my permission for Northgate Dental Care and their staff to leave phone messages regarding my medical care with the following sources:  ( Please intial each source you wish to receive messages at.)    
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • **This authorization will remain in effect until our office is notified in writing.

I understand if my account becomes delinquent, it may be forwarded to an outside collection agency without notice. If this happens, I will be responsible for all costs of collection, including but not limited to interest, rebilling fees, court cost, attorney fees and collection agency costs.

security code
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Enter Security Code:


Confirm Electronic Signature*