719-282-3400

 

Please fill out the form below to provide us with your information.  This will help us with our recordkeeping, and will save you the time and effort of filling out forms when you visit our office.
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Patient information
Name (first, last)
Address:
City, state, ZIP:
Phone (home)
Phone (work)
Phone (cell)
E-mail address:
Gender: male female
Marital status: married single divorced separated widowed n/a
Social Security number:
Birthdate:
Student status: full-time part-time n/a
Employment status: full-time part-time n/a
Employer:
How did you hear about us? Yellow Pages
insurance provider
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drive-by
other, please specify below
Referred by:
Guarantor Information
Name (first, last)
Relationship to patient: self spouse child other
Address:
City, state, ZIP:
Phone (home)
Phone (work)
Phone (cell)
Social Security number:
Birthdate:
Primary insurance information
Insurance company:
Address:
City, state, ZIP:
Policyholder (first, last)
Relationship to patient: self spouse child other
Group number:
ID number:
Birthdate:
Employer:
Secondary insurance information
Insurance company:
Address:
City, state, ZIP:
Policyholder (first, last)
Relationship to patient: self spouse child other
Group number:
ID number:
Birthdate:
Employer:
Medications
Check all that apply: I am under a physician's care now
I currently use controlled substances
I currently use tobacco products
I'm a woman currently nursing a baby
I'm a woman taking oral contraceptives
I'm a woman who is pregnant
I'm a woman who is trying to get pregnant
I'm currently taking medication, pills, or drugs
I'm on a special diet
I've been hospitalized in the past for a major operation
I've had a serious head or neck injury
I've taken (or am currently taking) Phen-Fen or Redux
Comments about these:
Allergies
Check all that apply:
acrylic
aspirin
codeine
 latex
local anethetics
metal
 other
penicillin
Comments about these:
Ailments
Check all that apply:
AIDS / HIV positive
Alzheimer's Disease
anaphylaxis
anemia
angina
arthritis / gout
artificial heart valve
artificial joint
asthma
blood disease
blood transfusion
breathing problem
bruise easily
cancer
chemotherapy
chest pains
cold sores / fever blisters
congenital heart disorder
convulsions
cortisone medicine
diabetes
drug addiction
easily winded
emphysema
epilepsy or seizures
 excessive bleeding
excessive thirst
fainting spells / dizziness
frequent cough
frequent diarrhea
frequent headaches
genital herpes
glaucoma
hay fever
heart attack / failure
heart murmur
heart pacemaker
heart trouble / disease
hemophilia
hepatitis A
hepatitis B or C
herpes
high blood pressure
hives or rash
hypoglycema
irregular heartbeat
kidney problems
leukemia
liver disease
low blood pressure
 lung disease
mitral valve prolapse
pain in jaw joints
parathyroid disease
psychiatric care
radiation treatments
recent weight loss
renal dialysis
rheumatic fever
rheumatism
scarlet fever
shingles
sickle cell disease
sinus trouble
spina bifada
stomach / intestinal disease
stroke
swelling of limbs
thyroid disease
tonsillitis
tuberculosis
tumors or growths
ulcers
venereal disease
yellow jaundice
Comments about these:
6 Month Smiles Mentor
6260 Woodmen Park View, Suite 150, Colorado Springs, CO 80923, 719-282-3400
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