Existing Patient Forms

Existing Patient Forms

Thank you for continuing to trust Gordon Dentistry with your dental care. We strive to provide you with the best possible dental care. Please fill out the appropriate dental patient forms completely. If you have any questions or need assistance, please ask us — we will be happy to help.

Annual Health History Update

We require an annual health history update for all current patients. Please download and complete this Patient Form and bring this completed health history with you to your appointment. If you wish to update your address, phone number, email, family or marital status, simply call or email us at [email protected]

New Insurance Benefits

So that we may verify your new dental insurance benefit, please email a photo of the front and back of your insurance card to [email protected] If you do not have an insurance card, please email the following information at least one week prior to your new patient appointment:

  • Patient Name, DOB, Subscriber number or Social Security number
  • Insured person’s name, DOB, Subscriber number or Social Security number
  • Employer Name and Group number
  • Insurance Company Full Name (Example – Delta Dental of Illinois)
  • Insurance Company Phone Number
  • Claims Address
  • Payor ID

Antibiotic Prophylaxis

The American Heart Association updated their recommendations for antibiotic prophylaxis to prevent infective endocarditis in April 2007. The following conditions warrant antibiotic prophylaxis: prosthetic cardiac valves, history of previous infective endocarditis, severe or unrepaired congenital heart disease, completely repaired congenital heart defect with prosthetic material or device during the first six months after the procedure, repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device, cardiac transplantation recipients who develop cardiac valvulopathy. Patients with a history of heart attack or stents or bypass surgery generally do not require antibiotic prophylaxis. Click below to learn more.

Total Joint Replacement Form

If you have had a full joint replaced, please review the attached form, complete the section in the lower right and bring it to your next appointment. Antibiotic prophylaxis is required after a full joint replacement for two years after the surgery. If you are unsure whether or not you require antibiotic prophylaxis, please call your surgeon’s office. Click below to download the Total Joint Replacement Form.

Complimentary Xrays

We will take any needed x-rays at no charge during your new patient appointment. Please allow 60 to 90 minutes for a comprehensive examination of your teeth, gums and soft tissue. Up to a $275 value! New patients only. Not valid with any other offer. ADA Codes D0150, D0210, D0272, D0330.


    No, thank you.