Patient Forms

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

PERSONAL INFORMATION

Items with* are required.

  • 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
  • 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
  • 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.

  • Secondary Insurance Coverage Secondary coverage will filed after the primary is finalized
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.

  • Yes No
  • Yes No
  • 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
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • >Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes >No
  • Yes No
  • Items with* are required. Are you taking any of the following?
  • Yes No
  • Yes No
  • 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
  • Yes No
  • Yes No
BLOOD PRESSURE
  • Yes No
  • Yes No
ALLERGIES Are you allergic or have you had a reaction to:
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
DRUGS, ALCOHOL, TOBACCO
  • Yes No
WEIGHT AND DIETARY CONSIDERATIONS


  • EPWORTH SLEEPINESS SCALE
  • How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?

    0 - Would never doze
    1 - Slight chance of dozing
    2 - Moderate chance of dozing
    3 - High chance of dozing

  • 0 - Would never doze
    1 - Slight chance of dozing
    2 - Moderate chance of dozing
    3 - High chance of dozing

  • 0 - Would never doze
    1 - Slight chance of dozing
    2 - Moderate chance of dozing
    3 - High chance of dozing

  • 0 - Would never doze
    1 - Slight chance of dozing
    2 - Moderate chance of dozing
    3 - High chance of dozing

  • 0 - Would never doze
    1 - Slight chance of dozing
    2 - Moderate chance of dozing
    3 - High chance of dozing

  • 0 - Would never doze
    1 - Slight chance of dozing
    2 - Moderate chance of dozing
    3 - High chance of dozing

  • 0 - Would never doze
    1 - Slight chance of dozing
    2 - Moderate chance of dozing
    3 - High chance of dozing

  • 0 - Would never doze
    1 - Slight chance of dozing
    2 - Moderate chance of dozing
    3 - High chance of dozing

  • 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.


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 $100 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.

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