Click here to return Home         FAMILY GENTLE DENTAL CARE
                                                        DR. DAN PETERSON

                                                                      1415 SAGE STREET ~ GERING, NEBRASKA 69341 
                                                             
      Call: 308-436-3491       www.dentalgentlecare.com           

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        New Patient History

Welcome

Thank you for selecting our dental team!

To help us meet your dental needs please fill out as much of the necessary information as you can in order to help us to serve you better. You may fill it out online; print it out and bring the completed form with you to your next appointment or fill it out and fax it to our office 308-436-3451.

Getting to know you!  

Last Name   First Name  

I prefer to be called

Gender: Female    Male                      

If the patient is a child, Parents name 

Birth date:    Age   

Single    Married    Divorced    Widowed    Separated  Child

Social Security # 

Driver's License number:

Street Address 

City    State   Zip

Home Phone (with area code) Pager

Cell Phone   Emergency Number

E-Mail Address

Previous dentist:    Last visit date:

Employer  

How long there

Employer's Address

          City   State

Work Phone   Extension  

Occupation

When and where are the best times to reach you?

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Spouse's Information

Spouse's Name   

Birth date

Social Security Number:  

Employer  

Work Number

Work Address

DL Number

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Emergency Information:

Nearest Relative (not living with you)   

Relative's Phone Number  

Work Phone #

Friend's Name and Address  

Friend's Phone #  

Friend's Work #

Whom May We Thank For Referring You:

Other Family Members Seen By Us

Doctor's Name

Phone #

Last doctor visit Date

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Responsible Party

Person Responsible For Account

Work Number Home #:

Billing Address

Relation

Social Security Number

Employer

Driver's License#

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Primary Dental Insurance

Insurance Company Name

Insurance Company Address

Insurance Company Phone #

Group # (Plan, Local or Policy #)

Insured's Name

Relation

Insured's Birth date Insured's S.S.#

Insured's Employer

Date insurance policy was started:

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This information is NOT shared with anyone outside this office. This material is strictly confidential and collected solely for the use of this office to process for your medical/dental records chart.  This data will be stored in your dental record. This information will not be shared with anyone without a written consent that is signed and dated only by you.

(WARNING: there is no encryption system protecting the confidentiality of any information from this from you my sent to us)

Thank you for taking the time to fill out this form.

Please fill our the Medical Update Form.

Please print out HIPPA Notification

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Wondering why you have to fill out these forms?  Visit Reasons for Dental Forms to find out the reasons.

                                       Back  Medical Update Form   Our Services    Home     Site Map

 

          If you have any questions please e-mail me at: drdpeterson@scottsbluff.net
                                                                                 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.