Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
*Birthdate:    
*Gender:  
*Present Age:  
School:
Grade:
Social Security #:
Employer
If patient is a minor, give parent's or guardian's name:
Has any other member of the family been treated in our office? If yes who?
Whom may we thank for referring you to our practice?
Family Dentist: Physician Name:
  Responsible Party Information   
Complete the following information for parent(s) with whom patient primarily resides (address listed above).
  
Name:
Marital Status:
Home Phone:
Birthdate:  
Email:
Cell Phone:
Employer:
Occupation:
# of years Employed Here:
Work Phone:
SS#:
  
Name:
Marital Status:
Home Phone:
Birthdate:  
Email:
Cell Phone:
Employer:
Occupation:
# of years Employed Here:
Work Phone:
SS#:
If applicable, complete the following information for the noncustodial secondary parent.
  
Name:
Marital Status:
Home Phone:
Birthdate:  
Email:
Cell Phone:
Employer:
Occupation:
# of years Employed Here:
Work Phone:
SS#:
  
Name:
Marital Status:
Home Phone:
Birthdate:  
Email:
Cell Phone:
Employer:
Occupation:
# of years Employed Here:
Work Phone:
SS#:
Emergency Information
Name of nearest relative not living with you:
Phone:
  Dental Insurance Information
Subscriber Name:
Subscriber ID:
Soc. Sec. #:
Insurance Company:
ID No.:
Birthdate:  
Insurance Co. Address:
Group No.:
Insurance Co. Phone:
Insured's Employer:
  Does dental insurance include orthodontics?    Do you have dual coverage?
If yes, complete the following:
Subscriber Name:
Subscriber ID:
Soc. Sec. #:
Insurance Company:
ID No.:
Birthdate:  
Insurance Co. Address:
Group No.:
Insurance Co. Phone:
Insured's Employer:
Medical Insurance Company:   
  Dental History     
Last Dental Visit:  
In the following questions, select yes or no whichever applies, to the patient
  Clenching or grinding of teeth?
  Clicking, popping or grating noise in the jaw joint?
With Pain?
How long?
  Discomfort, tightness or spasms of facial or neck muscles?
  Catching or locking of jaws?
  Periodontal disease or bleeding gums?
  Injury to neck, head, face or jaw?
  Injury or damge to mouth or any teeth?
  Previous orthodontic treatment or been treated for a bad bite?
  Wisdom teeth been removed?
  Brush teeth every day?
  Using a flouride mouth rinse or flouride supplements?
  Have any baby or permanent teeth been removed by a dentist?
Play a musical instrument?   What kind?
Was there any thumb or finger sucking?   Until what age?
What are your chief concerns in seeking treatment? (Please list all concerns)
   Medical History     
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
PLEASE EXPLAIN ALL POSITIVE RESPONSE BELOW.
  Rheumatic Fever
  Tuberculosis/Lung Disease
  Pneumonia
  Liver Disease
  Kidney Disease
  Heart Attack/Stroke
  Heart Disease
  Hepatitis, jaundice, or liver disease
  Congenital Heart Defect
  Heart Murmur
  Hemophilia/Bleeding Disorders
  High or Low Blood Pressure
  Snoring/Sleep Apnea
  Anemia
  Sinus Problems
  HIV/AIDS
  Tonsils/Adenoids Removed
  Cancer
  Handicaps/Disabilities
  Received Radiation Treatment
  Growth Problems
  Endocrine Problems
  Hormone Therapy
  Latex Allergy
  Metal Allergy
  Nervous Disorders
  Bone Disorders/Bone Loss
  Diabetes
  Seizures/Epilepsy
  Asthma
  Thyroid Problems
  Arthritis
  Treated for Psychiatric/Emotional Problems
  Ever Been Hospitalized
Has there been any change in health within the last year?  
Is patient currently under care of a physician?  
If so, when was the last visit and condition being treated?
Has a physician recommended taking antibiotics before dental procedures?  
Is there a history of surgery or x-ray treatment for a tumor, growth, or other condition of the head or neck?  
Is there difficulty breathing through the nose?  
If female, is patient currently pregnant?  
If any of the above medical questions were answered 'Yes' , please explain:
Please list any medications or drugs being taken:
Please list any drug allergies or sensitivities:
  AUTHORIZATION AND RELEASE    
(Signature Required)
I certify that I have read and understand the previous information and to the best of my knowledge, all questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. I authorize Gehring Orthodontics to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I understand that a credit bureau report may be obtained on all listed individuals. If you do not wish a credit bureau report run on a spouse or other listed party, do not list his/her contact information. I authorize and request my insurance company to pay directly to Gehring Orthodontics, including dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment for all services rendered on my behalf or dependents.
Signature:
Date: