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                                                        DR. DAN PETERSON

                                                                      1415 SAGE STREET ~ GERING, NEBRASKA 69341 
      Call: 308-436-3491           

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Oral health is essential to your general health 
and well-being .

Patients are often confused as to the reasons why they need to fill out medical and dental history forms.  People often do not realize how their dental health affects their physical health and how their physical health affects their dental health. 

      Dentist can help you become healthier by not only examining the inside of your mouth but also by helping you understand the mouth-body connection!

     Dental exams can reveal gum disease, cavities, oral cancer, poor oral health conditions that are linked to diabetes, heart disease and poor overall health. Because of how these risk factors are related to each other you will be asked additional questions regarding your health.  

     The answers to these questions help us determine risk factors to help us provide you with better treatment recommendations that are SPECIFIC TO YOU.  We can teach you what risk factors affect YOUR health.  We will do all we can to help you decrease your chances for heart disease, diabetes and other health problems.

     In addition many medications have side effects that affect oral health.  Two out of every five patients take some kind of medication that could have a dental related side effect!  With age, this fact doubles.

Fill out the medical form in the convenience of your home.

     Please take the time to complete :

                Medical History

                Patient Information Form

                Notice of Privacy Practices

                Patient Survey

You can send these forms by:

  1. Fax:  308-436-3451

  2. Mail them to us before your appointment: 1415 Sage Street, Gering NE 69641

  3. Bring them with you to your first appointment. 

We will have you sign and date them at your first appointmentThis will allows us to serve you faster and more efficiently.

     Be prepared to provide us with:

  1. Present medical condition

  2. Drug allergies

  3. Problems with medications

  4. Changes in any medication

  5. List of current medication and over the counter medications

  6. Last visit to doctor

  7. Are you taking a blood thinner?  When you take a blood thinner, there are concerns that you may bleed unusually heavily after an extraction or having your teeth cleaned.  It is important that your doctorís office contact us with a recent INR result before you have a cleaning, root planing, or any kind of dental surgery including extraction or gum surgery.  The INR result helps decide whether we can do the procedure with a high level of safety.    We canít stress enough that our office must have good communication  with your doctor to insure the greatest safety for you.

Working together we can choose the treatment most appropriate for you!


Please click here for: Medical History Form

Please click here for: Social History/Patient Information Form

Visit: The Mouth-Body Connection for more reasons, produced by the American Academy of Periodontology, & ADA.


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          If you have any questions please e-mail me at:
                                                                                 308-436-3491 Office number

PLEASE NOTE: The information contained herein is intended for educational purposes only.  It is not intended and should not be construed as the delivery of dental/medical care and is not a substitute for personal hands on dental/medical attention, diagnosis or treatment.  Persons requiring diagnosis, treatment, or with specific questions are urged to contact your family dental/health care provider for appropriate care.
This site is privately and personally sponsored, funded and supported by Dr. Peterson.  We have no outside funding.
Confidentiality of data including your identity, is respected  by this Web site. We undertake to honor or exceed the legal requirements of medical/health information privacy that apply in Nebraska.

Copyright ©1998-2008 Family Gentle Dental Care, all rights reserved.