Flatirons Endodontics, LLC :: Contact Information

850 W. South Boulder Rd
Suite 201
Louisville, CO 80027
303.665.6120
Office Hours: Mon-Thurs 8-5
Online Map/Directions

905 W. 124th Ave.
Suite 160
Westminster, CO 80234
303.214.4100
Office Hours: Tues-Fri 8-5
Online Map/Directions

Patient History Form

Address

Phone Number
- Area Code Phone Number
E-mail
Date of Birth
Month Day Year
Employer
General Dentist
Social Security #
PAYMENT INFORMATION - You are responsible for payment when services are rendered. If for any reason
your account goes to collections, you will be responsible for collection fees or any reasonable attorney fees.
Dental Insurance Information
Name of Insured
SSN/ID#
Insured's Date of Birth
Month Day Year
Relationship to Patient
Employer
Group #
Insurance Company Name
Local #

Insurance Company Address

Are you allergic to or have you had side affects from any of the following?

Do you have or have you had any of the following?

Other conditions not listed
Current medications
Recent hospitalizations
Have you ever been told to take antibiotic premedication prior to dental appointments?

Yes No
Women:
Are you pregnant?

Yes No
Nursing?

Yes No
Do you use birth control pills?

Yes No
Emergency Contact
Full Name
First Name Last Name
Phone Number
- Area Code Phone Number
I agree that the information above was provided by the patient or parent/guardian and is correct to the best of my knowledge:*

I agree
Should be Empty:

Louisville: 303.665.6120 Westminster: 303.214.4100