Confidential Patient Information    
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:  
*Gender:
*Address:
*City:
*State:
*Zip:
*Home Phone:
Cell Phone:
Email:
Social Security #:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does patient live with?        Other:  
Number of children in the family?
Please list the names of any family members currently in the practice or previously treated by Gersch Orthodontics:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
  Confidential Financial Party Information    
 
*First Name:
Middle Initial:
*Last Name:
Marital Status:
How long at this address?
*Main Phone:
2nd/Cell Phone:
Email:
*Birthdate:  
Relationship to Patient:
*Address:
*City:
*State:
*Zip:
Previous Address (less than 3 years)
Social Security #:
Employer:
Employer Address:
Occupation:
Length of Employment:
Work Phone #:
 
Spouse or other parent's first name:  
Middle Initial:  
Last Name:  
Social Security #:  
Employer:  
Occupation:
Birthdate:  
Length of Employment:
Work Phone #:
Relationship to Patient:
  Dental Insurance Information    
Primary Dental Insurance
Policy Holder's Name:
Birthdate:
Insurance Company:
SS#:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
Do you have dual dental coverage?   (If yes, please complete information below)
Secondary Dental Insurance
Policy Holder's Name:
Birthdate:
Insurance Company:
SS#:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
 
  Dental History     
Dentist Name:
Check-up Frequency:   
Last Dental Visit:  
Has the patient had an orthodontic consult or treatment?
If so, when?

Does the Patient need to premedicate prior to dental visit?  
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
 Speech problems/therapy?
 Clench or Grind Teeth?
 Oral habits (thumb/finger sucking, lip/nail  biting)?
 Injury to face, jaw, teeth or mouth?
 Discomfort from teeth or gums?
 Pain, tenderness or noise in either jaw?
 Frequent headaches?
 Neck/shoulder pain?
 Frequent sore throats?
 Chipped or injured permanent teeth?
 Teeth sensitive to hot or cold?
 Previous root canal therapy?
 Bad taste/mouth odor?
 Previous periodontal (gum) treatment?
 Abnormal swallowing (tongue thrust)?
 Teeth that irritate tongue, cheek, lip, etc?
 Numerous fillings?
 Brush teeth daily?
 Floss teeth daily?
 Fluoride treatments?
 Mouth breathing?
 Snores during sleep?
 Any missing or extra permanent teeth?
 Apprehensive about dental care?
 Frequently Chew Gum?
 Thumb or finger habit as a child?
 Jaw fractures, cysts, mouth infections?
 Bleeding gums?
 Other periodontal (gum) problems?
 Frequent canker sores or cold sores?
 Have wisdom teeth been removed?
 Problems with food trapped between teeth?
 Is all dental work completed at this time?
Please use the space below to elaborate on the above 'Yes' answers:
   Medical History     
Physician Name:
Address:
City:
State:
Zip:
Date of Last Physical:
Patient Health:
   Has there been any change in the patient's general health within the last year?
   Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
   Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
 Latex  Penicillin or other antibiotics
 Sulfa drugs  Aspirin, Ibuprofen, Tylenol
 Local anesthetics  Codeine or other narcotics  
 Other
List any drug allergies or sensitivities (not listed above) that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
 Heart Murmur
 Damaged or artificial heart valves
 Congenital Heart Defect
 Heart Disease
 Rheumatic Fever
 Angina
 Liver Disease / Jaundice / Hepatitis
 Kidney Disease
 Heart Attack/Stroke
 Hemophilia
 Hypertension/High Blood Pressure
 Prolonged Bleeding/Transfusion
 Anemia / Blood disorder
 HIV/AIDS
 Tonsils/Adenoids Removed
 Handicaps/Disabilities
 Arthritis / Joint problems
 Large Tonsils
 Sinus trouble
 Bed wetting
 Substance abuse problem (past or present)
 Bone fractures/trauma to face/jaw
 Prosthetic joints
 Chronic fatigue
 Diabetes
 Growth Problems
 Tuberculosis or Lung Disease
 Pneumonia
 Cancer
 Family History of Cancer
 Received Radiation Treatment
 Arteriosclerosis
 Thyroid / Endocrine Problems
 Stomach ulcer or hyperacidity
 Hormone Therapy
 Metal Allergy
 Nervous Disorders
 Bone Disorders/Bone Loss
 Seizures / Epilepsy / Neurological Disease
 Treated for Emotional Problems
 Asthma
 Respiratory problems / Emphysema
 Persistent swollen neck glands
 Sexually transmitted disease
 Low blood pressure
 Persistent cough
 FEMALES: Are you pregnant
 Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:
  Patients Under 18    
If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Has either biological parent ever had orthodontic treatment:
 
PRIVACY NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
  • To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.);
  • To third party payers or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.);
  • To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
  • Internally, to all staff members who have any role in your treatment;
  • To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.;
  • To your family and close friends involved in your treatment; and/or,
  • We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.
 
Under the new privacy rules, you have the right to:
  • Request restrictions on the use and disclosure of your protected health information;
  • Request confidential communication of your protected health information;
  • Inspect and obtain copies of your protected health information through asking us;
  • Amend or modify your protected health information in certain circumstances;
  • Receive an accounting of certain disclosures made by us of your protected health information; and,
  • You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).
We have the following duties under the privacy rules:
  • By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
  • To abide by the terms of our Privacy Notice that is currently in effect;
  • To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy Notice.
Please note that we are not obligated to:
  • Honor any request by you to restrict the use or disclosure of your protected health information;
  • Amend your protected health information if, for example, it is accurate and complete; or,
  • Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.
This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Contact Person or direct your questions to this person at our office address. Thank you.
 
PATIENT ACKNOWLEDGEMENT
 
 
Name of Patient:    Responsible Party Initial: