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 fileName First Last New Information OnlyNew Name First Middle Last New Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Marital StatusMarriedSingleGenderFemaleMaleNew Work PhoneNew Cell PhoneNew Home PhoneNew Other PhoneNew Email Best Way to ContactEmailTextPhoneI give Northgate Dental permission to leave messages for me on my voice mail or with persons at my residence.*YesNoNew Emergency Contact PersonNew Phone for Emergency Contact PersonIn 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 OnlyInsuranceI do NOT have dental insuranceI do HAVE dental insuranceI have more than one dental policyNew 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 NameNew Subscriber Date of BirthNew Subscriber ID #New Subscriber EmployerNew Group NumberNew Insurance CarrierAetnaBlue Cross/Blue ShieldCignaDelta DentalDentamaxDWPGuardianHumanaMetLifeUnited ConcordiaUnited HealthcareOtherNew Insurance Carrier Claim AddressInsurance Carrier Phone NumberNew Secondary Insurance Coverage Secondary coverage will filed after the primary is finalizedNew Secondary Insurance CarrierSecondary SubscriberSecondary EmployerSecondary Group Number Change in Health Since Last VisitHeart (Surgery, Disease, Attack)YesNoHepatitis, Any FormYesNoHeart Murmur (mitral valve prolapse)YesNoRheumatic FeverYesNoJoint ReplacementYesNoHIV Infection/AIDSYesNoTaken Fen-Phen or other diet pillsYesNoDiabetesYesNoAsthmaYesNoHave you had a visit to your physician since your last dental visit?YesNoIf yes, please listDo you have any allergies to medications or latex?YesNo For Women OnlyAre you pregnant?YesNoAre you a nursing mother?YesNo Are you taking or have you ever taken the following Bisphosphonate (Osteoporosis ) Medications?Alendronate/FosamaxYesNoRisedronate/ActonelYesNoEtidronate/DidronelYesNoTiludronate/SkelidYesNoPamidronate/ArediaYesNoIbandronate/BonivaYesNoZoledronate/ZometaYesNoConsent 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 PhoneYesNoWork PhoneYesNoSpouseYesNoSpouse NameOtherYesNoOther NamePlease contact me personally and do not leave detailed messages regarding my careYesNoElectronic 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.CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.