Patient Health History Update

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.

CURRENT PATIENT HEALTH HISTORY UPDATE