New Patient Forms

New Patient Form

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.n

Step 1 of 7

14%

Personal Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Birthdate*
Enter as mm/dd/yyyy
Marital Status
- Married
- Single
Gender
- Male
- Female
Work Phone
Home Phone
Cell Phone
Other
Email
Best Contact Phone*
- Work
- Cell
- Home
- Other
I give Northgate Dental permission to leave messages for me on my voicemail or with persons at my residence.*
- Yes
- No
Emergency Contact*
First Last
Emergency Contact Phone
How did you hear about Northgate Dental?
- From one of our patients
- TV
- Radio
- Internet
- Mail
- Other
Name of patient referral
If you checked "Patient" from the above list, please tell us their name so we can 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
Please choose the one that is applicable
- I do NOT have dental insurance
- I do HAVE dental insurance
- I have more than one dental plan
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 #
Group Number
Insurance Carrier
- Aetna
- Blue Cross/Blue Shield
- Cigna
- Delta Dental
- Dentamax
- DWP
- Guardian
- Humana
- MetLife
- United Concordia
- United Healthcare
- Other
Insuranc 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
Reason for hospitalization
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
Heart Murmur (Mitral Valve Prolapse)
- Yes
- No
Abnormal Heart or Previous Bacterial Endocarditis
- Yes
- No
Heart Stent
- Yes
- No
Heart (Surgery, Disease, Attack)
- Yes
- No
Heart Valve (artificial) or Heart Transplant
- Yes
- No
If yes, when placed?
Joint Replacment
- Yes
- No
Rheumatic Fever
- Yes
- No
Hepatitis
- Yes
- No
HIV Infection/AIDS or ARC
- Yes
- No
Emphysema or other Respiratory Illnesses
- Yes
- No
Kidney Disease
- Yes
- No
Venereal Disease
- 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
Headaches
- Yes
- No
Present or previous drug addiction
- Yes
- No
Unintentional weight Loss/Gain
- Yes
- No
Recurrent Illnesses
Other conditions
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
St. John's Wort or Kava-Kava?
- Yes
- No
Barbituarates (any)
- 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
Allergies
Are you allergic or have you had a reaction to:Are you allergic or have you had a reaction to:
Local anesthetics
- Yes
- No
If yes, please clarify:
Penicillin or other antibiotics
- Yes
- No
If yes, please clarify:
Aspirin, Ibuprofen or Tylenol?
- Yes
- No
If yes, please clarify:
Codeine, Valium or other sedatives
- Yes
- No
If yes, please clarify:
Latex or Metals?
- Yes
- No
If yes, please clarify:
Other, please specify

Drugs, Alcohol, Tobacco
Do you use Tobacco?
- Yes
- No
If yes, select type
- Smoke
- Chew
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
- None
- Some
- Moderate
- High

Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?
Sitting and reading
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
Watching TV
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
Sitting inactive in a public space (eg. a theater or a meeting)
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
As a passenger in a car for an hour without a break
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
Lying down to rest in the afternoon when circumstances permit
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
Sitting and talking to someone
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
Sitting quietly after a lunch, without alcohol
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
In a car while stopped for a few minutes in traffic
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
Electronic Signature*
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.
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.
Captcha

You may refuse to fill out this acknowledgement. By filling out these forms, you are verifying that you have received a copy of this office’s Notice of Privacy Practices.

IF YOU ARE UNCOMFORTABLE WITH THE ONLINE INTAKE FORM, PLEASE DON’T HESITATE TO CALL: 719-488-2292. Marissa, TOMMIE OR SHELLY WILL BE HAPPY TO MAIL, OR EMAIL THE FORMS TO YOU.

I AM THE “PERSONAL REPRESENTATIVE” AND HAVE LEGAL AUTHORITY TO MAKE HEALTH CARE DECISIONS ABOUT THE FOLLOWING PATIENT:

New Patient Form

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.n

Step 1 of 7

14%

Personal Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Birthdate*
Enter as mm/dd/yyyy
Marital Status
- Married
- Single
Gender
- Male
- Female
Work Phone
Home Phone
Cell Phone
Other
Email
Best Contact Phone*
- Work
- Cell
- Home
- Other
I give Northgate Dental permission to leave messages for me on my voicemail or with persons at my residence.*
- Yes
- No
Emergency Contact*
First Last
Emergency Contact Phone
How did you hear about Northgate Dental?
- From one of our patients
- TV
- Radio
- Internet
- Mail
- Other
Name of patient referral
If you checked “Patient” from the above list, please tell us their name so we can 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
Please choose the one that is applicable
- I do NOT have dental insurance
- I do HAVE dental insurance
- I have more than one dental plan
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 #
Group Number
Insurance Carrier
- Aetna
- Blue Cross/Blue Shield
- Cigna
- Delta Dental
- Dentamax
- DWP
- Guardian
- Humana
- MetLife
- United Concordia
- United Healthcare
- Other
Insuranc 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
Reason for hospitalization
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
Heart Murmur (Mitral Valve Prolapse)
- Yes
- No
Abnormal Heart or Previous Bacterial Endocarditis
- Yes
- No
Heart Stent
- Yes
- No
Heart (Surgery, Disease, Attack)
- Yes
- No
Heart Valve (artificial) or Heart Transplant
- Yes
- No
If yes, when placed?
Joint Replacment
- Yes
- No
Rheumatic Fever
- Yes
- No
Hepatitis
- Yes
- No
HIV Infection/AIDS or ARC
- Yes
- No
Emphysema or other Respiratory Illnesses
- Yes
- No
Kidney Disease
- Yes
- No
Venereal Disease
- 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
Headaches
- Yes
- No
Present or previous drug addiction
- Yes
- No
Unintentional weight Loss/Gain
- Yes
- No
Recurrent Illnesses
Other conditions
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
St. John's Wort or Kava-Kava?
- Yes
- No
Barbituarates (any)
- 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
Allergies
Are you allergic or have you had a reaction to:Are you allergic or have you had a reaction to:
Local anesthetics
- Yes
- No
If yes, please clarify:
Penicillin or other antibiotics
- Yes
- No
If yes, please clarify:
Aspirin, Ibuprofen or Tylenol?
- Yes
- No
If yes, please clarify:
Codeine, Valium or other sedatives
- Yes
- No
If yes, please clarify:
Latex or Metals?
- Yes
- No
If yes, please clarify:
Other, please specify

Drugs, Alcohol, Tobacco
Do you use Tobacco?
- Yes
- No
If yes, select type
- Smoke
- Chew
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
- None
- Some
- Moderate
- High

Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?
Sitting and reading
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
Watching TV
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
Sitting inactive in a public space (eg. a theater or a meeting)
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
As a passenger in a car for an hour without a break
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
Lying down to rest in the afternoon when circumstances permit
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
Sitting and talking to someone
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
Sitting quietly after a lunch, without alcohol
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
In a car while stopped for a few minutes in traffic
- 0-Would never doze
- 1-Slight chance of dozing
- 2-Moderate chance of dozing
- 3-High chance of dozing
Electronic Signature*
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.
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.
Captcha

New Patient Form

Step 1 of 7

Personal Information

Insurance

Health History

For Women Only

Blood Pressure

Allergies

Drugs, Alcohol, Tobacco

Weight and Dietary Considerations

Epworth Sleepiness Scale