Patient Health History Update - Northgate Dental

CURRENT 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 INFORMATION BELOW. QUESTIONS? PLEASE CALL 719-488-2292.

Step 1 of 5

20%

Name we Currently have on file
Name
First Last
New Information Only
New Name
First Middle Last
New Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Marital Status
Married
Single
Gender
Female
Male
New Work Phone
New Cell Phone
New Home Phone
New Other Phone
New Email

Best Way to Contact
Email
Text
Phone
I give Northgate Dental permission to leave messages for me on my voice mail or with persons at my residence.*
Yes
No
New Emergency Contact Person
New Phone for Emergency Contact Person
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
Insurance
I do NOT have dental insurance
I do HAVE dental insurance
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 Subscriber Name
New Subscriber Date of Birth
New Subscriber ID #
New Subscriber Employer
New Group Number
New Insurance Carrier
Aetna
Blue Cross/Blue Shield
Cigna
Delta Dental
Dentamax
DWP
Guardian
Humana
MetLife
United Concordia
United Healthcare
Other
New Insurance Carrier Claim Address
Insurance Carrier Phone Number
New Secondary Insurance Coverage Secondary coverage will filed after the primary is finalized
New Secondary Insurance Carrier
Secondary Subscriber
Secondary Employer
Secondary Group Number

Change in Health Since Last Visit
Heart (Surgery, Disease, Attack)
Yes
No
Hepatitis, Any Form
Yes
No
Heart Murmur (mitral valve prolapse)
Yes
No
Rheumatic Fever
Yes
No
Joint Replacement
Yes
No
HIV Infection/AIDS
Yes
No
Taken Fen-Phen or other diet pills
Yes
No
Diabetes
Yes
No
Asthma
Yes
No
Have you had a visit to your physician since your last dental visit?
Yes
No
If yes, please list
Do you have any allergies to medications or latex?
Yes
No

For Women Only
Are you pregnant?
Yes
No
Are you a nursing mother?
Yes
No

Are you taking or have you ever taken the following Bisphosphonate (Osteoporosis ) Medications?
Alendronate/Fosamax
Yes
No
Risedronate/Actonel
Yes
No
Etidronate/Didronel
Yes
No
Tiludronate/Skelid
Yes
No
Pamidronate/Aredia
Yes
No
Ibandronate/Boniva
Yes
No
Zoledronate/Zometa
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.)
Home Phone
Yes
No
Work Phone
Yes
No
Spouse
Yes
No
Spouse Name
Other
Yes
No
Other Name
Please contact me personally and do not leave detailed messages regarding my care
Yes
No
Electronic Signature
**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.
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Our Vision

• To create meaningful, long lasting relationships with love, empathy and compassion.
• To preserve integrity with steadfast moral character, ethical principles and resounding honesty.
• To provide everyone with the opportunity to make life changing decisions that encourage personal freedom and joy.

Open Hours

Monday through Thursday
8am to 4pm

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Contact Info

1016 Middle Creek Parkway Colorado Springs, CO 80921
Phone: (719) 488-2292
Email: info@NorthGateDentalCare.com

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