Patient Forms

If you are uncomfortable with the online intake form, please don't hesitate to call: 719-488-2292. Candace or Amy will be happy to mail, or email the forms to you.

PERSONAL INFORMATION

Items with* are required.
First Name*		Middle Name
Last Name*
Street Address*
Apt #		City*
State*		Zip*
Birthdate*
Marital Status	Married Single	Gender	Female Male
Work Phone		Cell Phone
Home Phone*		Other
Email Address*		Best Contact Phone*
I give Northgate Dental permission to leave messages for me on my voice mail or with persons at my residence.*			Yes No
Emergency Contact Person*		Phone for Emergency Contact*
How did you hear about Northgate Dental
If you checked 'Patient' from the above list, please tell us their name so we may thank them

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

Select One*	I do NOT have dental insurance I do HAVE dental insurace I have more than one dental policy

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.
Subscriber Name		Subscriber Date of Birth
Subscriber Employer		Subscriber ID#
Insurance Carrier		Group Number
Insurance Carrier Claim Address		Insurance Carrier Phone Number
Secondary Insurance Coverage Secondary coverage will filed after the primary is finalized
Other Insurance Carrier		Secondary Subscriber
Secondary Employer		Secondary Insurance Carrier
Secondary Group Number		Secondary Subscriber

HEALTH HISTORY

Health History is very important for most types of dental treatment, but especially important if you are considering any form of Sedation. Medications and certain medical conditions can affect treatment outcomes. Please be as thorough as possible.
Date and purpose of last medical exam*
Have you been hospitalized in the past 5 years?*	Yes No	If yes, please state reason
Are you currently receiving care?	Yes No	Please list name and phone of all physicians who are currently providing care. State NONE if that applies.
For the following questions choose yes or no. Your answers are for our records only and will be confidential. Please note that during your initial visit you will be asked some questions about your response. Our team may ask additional questions concerning your health
Anemia or Blood Disorder	Yes No	Arthritis, Rheumatism or other inflammatory disease	Yes No
Diabetes	Yes No	Epilepsy	Yes No
Fainting or Dizzy spells	Yes No	Abnormal Heart or Previous Bacterial Endocarditis	Yes No
Heart Murmur (mitral valve prolapse)	Yes No	Heart (Surgery, Disease, Attack)	Yes No
Heart Valve (artificial) or Heart Transplant	Yes No
Heart Stent	Yes No	If yes, when placed
Joint Replacement	Yes No	If yes, when
Rheumatic Fever	Yes No	Hepatitis	Yes No
Emphysema or other Respiratory Illnesses	Yes No	Kidney Disease	Yes No
Venereal Disease	Yes No	HIV Infection/AIDS or ARC	Yes No
Snoring/Sleep Apnea	Yes No	Bruxism (grinding or clenching teeth during day/night)	Yes No
Psychosis	Yes No	Glaucoma	Yes No
Asthma	Yes No	Abnormal bleeding when cut	Yes No
Are you taking blood thinners? (including aspirin or coumidin)	Yes No	Sore or enlarged lymph nodes	Yes No
Previous biopsies	Yes No	Radiation or Chemotherapy Treatment	Yes No
Liver Disease (including Jaundice)	Yes No	Slow-Healing Mouth Sores	Yes No
Do you have headaches?	Yes No	Present or previous drug addiction?	Yes No
Unintentional weight Loss/Gain	Yes No	Other Conditions
Recurrent Illnesses

Items with* are required. Are you taking any of the following?
Have you been told you should Pre-Medicate before any dental treatment?	Yes No	Do you use antacids?	Yes No
Dilantin or Tegretol?	Yes No	Barbituarates (any)	Yes No
St John's Wort or Kava-Kava?	Yes No	Tagamet (cimetidine) or Prilosec (omeprazole)?	Yes No
Cardizem (diltiazem) or Calan, Isoptin (Verapamil)?	Yes No	Serzone (nefazodone)	Yes No
Diflucan (fluconazole) or Sporonox (itraconazole)	Yes No	Biaxin (clarithromycin)?	Yes No
Have you ever been treated with Biophosphate drugs (Fosomax, Aredia, Zometa, Actonel, Boniva)?	Yes No	If yes, when did treatment begin?
When did treatment stop?		Have you ever taken fen-phen for weight loss?	Yes No
Do you consume grapefruit juice, grapefruits or grapefruit extract?	Yes No
Please list ALL medications you are taking
Please list all dietary or herbal supplements you are taking and for what purpose

FOR WOMEN ONLY

Are you pregnant?	Yes No	Are you planning a pregnancy in the near future?	Yes No
Are you a nursing mother?	Yes No	Are you taking birth control pills?	Yes No

BLOOD PRESSURE

Do you have abnormal blood pressure?	Yes No	Have you ever received a diagnosis of high blood pressure?	Yes No
Are you allergic or have you had a reaction to:
Local anesthetics	Yes No	Penicillin or other antibiotics	Yes No
Aspirin, Ibuprofen or Tylenol?	Yes No	Codeine, Valium or other sedatives	Yes No
Latex or Metals?	Yes No	Other, please specify

DRUGS, ALCOHOL, TOBACCO

Do you use Tobacco?	Yes No	If yes, select type
How long have you used tobacco products?		How much per day?

WEIGHT AND DIETARY CONSIDERATIONS

Weight		Meals per day
Dietary Restrictions		Food Allergies
Amount of sugar in your diet

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of change in my health and medication.

Electronic Signature*
General Consent I am aware that the practice of dentistry and dental surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the results of the surgery or dental procedure(s). I understand that there are certain inherent and potential risks associated with treatment or restorations. I understand that the nerve inside my tooth may be irritated by treatment and I may experience pain or discomfort during and/or after treatment. My tooth/teeth may temporarily become more sensitive to hot and cold liquids and foods. I understand that in some cases additional treatment may become necessary at any point during or after treatment and may not be avoidable. I understand that there are certain inherent risks and consequences that may be associated with any surgical, dental or anesthetic/sedative procedure(s). I understand that not every conceivable hazard can be listed. I realize the following possibilities exist, however infrequent or rare: allergic reactions to medications, anesthetics, and other products and materials; drug interactions and side effects; excessive bleeding, both during and after procedure; postoperative bruising and discomfort; blood clots anywhere in the body; postoperative infections; bone inflammation; possible involvement of the nerve within the lower jaw during removal of lower teeth, resulting in usually temporary but sometimes permanent numbness and/or tingling in the lower lip and/or tongue; fracture or dislocation of the jaw; bruising and/or vein inflammation at the site of injections; damage to adjacent teeth, restorations and/or gum tissue. 50% of all teeth treated will need future treatment. These are not probable results, they are statistical possibilities. I understand that I may ask any questions I wish, regarding any treatment that is proposed and that it is better to ask questions before treatment begins than to wonder about it after treatment has started. I have been informed and fully understand that there are certain inherent and potential risks associated with treatment or restorations. Authorization I hereby authorize Northgate Dental (NGD) to submit insurance claims on my behalf with the understanding that NGD may not be a contracted provider and that I am responsible for all costs of dental treatment. I further authorize Northgate Dental to roll any past due balances to an outside line of credit. I also understand that Northgate Dental reserves the right to issue a cancellation fee of 0 per hour for any appointment cancelled within 48 business hours. I hereby authorize Northgate Dental to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. I also authorize Northgate Dental to perform any credit check necessary to extend financing options to me. All information and medical/dental history that I have provided is correct to the best of my knowledge. I grant the right to the dentist to release my medical/dental history and any other information about my dental treatment to third party payers and other health professionals. I acknowledge that I have read and understood Northgate Dental privacy practice.

Confirm Electronic Signature*


Northgate Dental Care: Dr Paul Dodsworth DDS 12225 Voyager Parkway, Suite 6 Colorado Springs, CO 80921-3754 Phone: (719) 488-2292 email: info@northgatedentalcare.com	Quick Links Request an Appointment \| New Patient Forms Case Studies \| Sleep Apnea \| Our Team \| Contact Us	Copyright © 2011 Northgate Dental Care All Rights Reserved.