Patient Health History Update

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

  • Name we Currently have on file

  • New Information Only

  • 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.

Your smile is our passion, and experience is our power. 

PHONE

(719) 488-2292

ADDRESS

1016 Middle Creek Parkway, Colorado Springs, CO, 80921-3754

EMAIL

info@northgatedentalcare.com

HOURS

Mon: 8:00am - 3:30pm

Tues: 8:00am - 4:00pm

Wed: 8:00am - 3:30pm

Thurs: 8:00am - 4:00pm

Fri-Sun: CLOSED

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