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Patient Form

Patient Form

- Step 1 of 5

Patient Information

Please pick from the following: *

Child
Adult

Patient's Name *

Date of Birth *

Age *

Gender *

Male
Female

Height *

Weight *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Home Phone

Email Address *

Patient's Dentist (of adult/child) *

Address (Dentist) *

Patient's Physician (of adult)

Patient's Oral Surgeon (of adult/child) *

Patient's Pediatrician (of child)

Summer/School Camp

Who may we thank for referring you to our office?

Confidential Responsible Party Information

(If patient is under 18)

Name

Marital Status

S
M
W
D

Residence

Own
Rent

Residence Address

Address Line 1

Address Line 2

City

State

Zip Code

How long at this address?

Home Phone

Work Phone

Previous Address (if less than 3 yrs.)

Address Line 1

Address Line 2

City

State

Zip Code

Social Security #

Date of Birth

Relationship to Patient

Employer

Occupation

No. Years Employed

Spouses' Name

Relationship to Patient

Employer

Occupation

No. Years Employed

Social Security #

Date of Birth

Insurance Information

(If patient is under 18)

Policy Holder’s Name *

Soc.Sec. #

Insurance Company

Group No.

Union Local No.

Insurance Co. Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Co. Phone

Employer

Marital Status

S
M
W
D

Cell Phone

Work Phone

Email

Birthdate

Policy Holder’s Employer

Do you have dual coverage?

Yes
No

If yes, Policy Holder’s Name

Soc. Sec. #

Insurance Company

Group No.

Union Local No.

Insurance Co. Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Co. Phone

Policy Holder’s Employer

Emergency Information

Name of nearest relative not living with you *

Complete Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Relationship to Patient *

I understand that where appropriate, credit bureau reports may be obtained.

PATIENT’S MEDICAL HISTORY

Please answer the following questions to the best of your knowledge.

Is patient in good health? *

Yes
No

Does patient have any history of major illness? *

Yes
No

Has patient ever been under the care of a physician for illness? *

Yes
No

Please explain

Has patient ever been hospitalized? *

Yes
No

If yes, for what?

Date of last examination by physician

Does patient bruise easily? *

Yes
No

Has patient ever required a blood transfusion? *

Yes
No

Does patient have tendency to colds? *

Yes
No

Sore throats? *

Yes
No

Have tonsils and/ or adenoids been removed? *

Yes
No

If yes, at what age?

Does patient have chronic ear pain or infections? *

Yes
No

Does patient take sedatives, tranquilizers, sleeping pills or medicine to relax? *

Yes
No

Does patient have trouble sleeping? *

Yes
No

Does patient snore when sleeping? *

Yes
No

Has the patient traveled to Guinea, Liberia, or Sierra Leone in the past 21 days? *

Yes
No

If yes, date:

Is patient feeling fever ish? *

Yes
No

List any drugs or medications now or previously taken:

Does the patient have any known allergies?

PATIENT’S DENTAL HISTORY

Date of patient’s last dental examination or treatment

Has patient had any serious problems associated with previous dental treatment? *

Yes
No

Have there been any injuries to your face, mouth or teeth? *

Yes
No

Has there been any treatment for problems of your jaw joint or for facial muscle spasms? *

Yes
No

Has the patient ever sucked a thumb or fingers? *

Yes
No

if yes, until what age?

Does the patient have any speech problems? *

Yes
No

Is the patient a mouth breather? *

Yes
No

if yes, at what times

Have you been informed of any missing or extra teeth? *

Yes
No

Does food catch or collect between teeth? *

Yes
No

Does the patient clench or grind their teeth? *

Yes
No

Is there clicking, popping or grating noise from the patient’s jaw when chewing? *

Yes
No

Is there numbness or tingling associated with the patient’s mouth or face? *

Yes
No

Has the patient ever had orthodontic treatment or been treated for a bad bite? *

Yes
No

Has an orthodontist been consulted previously? *

Yes
No

Has the patient ever had periodontal (gum) disease? *

Yes
No

Has either parent had orthodontic treatment? *

Yes
No

Has either parent had periodontal disease? *

Yes
No

Does the patient use a mouthguard during sports? *

Yes
No

List any musical instruments played:

Patients Name *

Please check all that are important to you and provide us any additional information you would like to share.

(If patient is under 18)

1. Treatment Time *

I have an event and I want to show off my smile
I will be moving or leaving the area
Build my confidence
Just because
Other

If other, please specify:

2. Frequency of Visits: *

I have a full schedule with work and/or after school activities
I will be driving a long distance to the appointments
Time is precious to me

3. Appearance of braces - I don’t want braces to show because: *

Of my career
I don’t like the way braces look
Confidence
Just because

4. Comfort: *

I am concerned about pain and discomfort
Doctors make me nervous
Other

If other, please specify: (copy)

5. Price:

I want to discuss an interest free payment plan

Please rest assured that Dr. Gellerman is not willing to let finances stand in the way of a patient’s desired treatment. We will work to find a financial arrangement that will fit within your budget.

6. Best Result: *

I am interested in a cosmetic fix, not the overall bite.
I want the best result. A beautiful smile with a healthy occlusion.
I/We/He/She is/are so excited to start treatment…Let’s rock and roll!

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I agree to the terms of the Privacy Policy

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Our Location

165 Main St.
Huntington, NY 11743

631-427-8444

Invisalign Diamond provider 2019

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Testimonials

Dr Gellerman and her staff are second to none! They are extremely knowledgeable, friendly and professional. The office is state of the art and equipped with all of the latest technology.... This was by the far the best experience my kids have had at a dental office, they are looking forward to going back!read more

Nancy E.

The office is clean, bright and state of the art. Staff is caring and professional. Dr Gellerman is excellent.

Kim M.

I love this experience. Not only are they a well-oiled machine, but they are personal. I can always talk to Dr. Gellerman, when needed, and we are never rushed. She is open to all of our... questions and always finds the best solution for our family. Love this practice!read more

Tracy P.

The office is clean, bright and state of the art. Staff is caring and professional. Dr Gellerman is excellent.

Kim M.

I was 💯satisfied with my oldest daughter treatment a few years ago so I decided to start a second child treatment ASAP .Treatment is going great for my youngest child right now,... They have since added a weekly monitor device that is super help with the treatment jorney. Both children had/has difficult over/ under bites.read more

Shanda R.

Dr Gellerman, took her time and expertise to see my daughter and give me her option. All the staff is so friendly. I recommend Dr Gellerman's office for orthodontic treatment

Paula P.

We love Dr. Gellerman’s office! From the time you step foot in the door, you can see your child’s comfort is their top priority. Dr. Gellerman is a pillar in the Huntington community and... she and her entire staff are absolutely amazing. They are friendly, attentive, and go out of their way to not only make sure the parents understand the orthodontic plan but the child does as well. The coordinator Karen spent so much time with my 9 year old son talking directly to him to answer his questions and explain the process he was going to be going through. Every person in the office that we have come in contact with has just been such a joy and has made my sons experience something he excited about and not fearful of. Truly top of the line care! We highly recommend Dr. Gellerman’s office for your orthodontic needs!read more

Cristina M.

amazing i love the staff and a beautiful work space, i love my new smile. the workers are so kind and fun to be around, the records tech is the best 😉 the girls are so beautiful and... kind and the doctors are wonderful and so good at what they do ❤️ im so glad i have an amazing smile that came from an amazing placeread more

angiee

Amazing!!! From the consult to process Gellerman Orthodontics has been fantastic. Fully explaining every step and ensuring my child’s comfort… they’ve been wonderful!

Diamandia B.

I was so blown away by the level of detail and depth of knowledge of the staff! One of the only orthodontists that understands myofunctional therapy and how it relates to total healthy of... body! Everything is very clean, and they are very comprehensive! You won't be disappointed here!read more

Christine M

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OUR LOCATION

165 Main St.
Huntington, NY 11743

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Contact

Call: (631) 427-8444

Fax: (631) 470-7837

Location

165 Main St.
Huntington, New York 11743

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Office Hours

Monday: 10:00 am - 7:00 pm
Tuesday: 10:00 am - 3:30 pm
Wednesday: 10:00 am - 7:00 pm
Thursday: 10:00 am - 6:00 pm
Friday: 10:00 am - 2:00 pm
Saturday: (Open 2 Saturdays a month 9:00 am - 2:00 pm)

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Homepage
Palatal Expansion (MARPE)
20 Years of Smiles
Calculate Payments
Payment Calculator
How to Fix an Overbite, Increase Airway Volume, and Improve Your Appearance with One Appliance
Hometown Hero Contest
Hometown Hero – Thank You
Current Patient Virtual Consultation
Free Virtual Consultation
Online Smile Assessment
Homepage
Headache Relief
TMJ-TMD Treatment In Huntington, NY
Sleep and Wellness at Gellerman Orthodontics
Integrative Orthodontics In Huntington, NY
Sleep Apnea Treatment In Huntington, NY
Surgical Treatment
Two-Phase Treatment
Board Certification
Patient Form
Mouthguard Program
Our Dream Team
Suresmile Huntington, NY
Contact Us – Thank You
Orthodontist or Dentist?
What Sets Us Apart
Español
Patient Resources
- New Patient Forms
- Your First Visit
- Payment Plans
- Life with Braces
- Retainer Appliance
- Palatal Expander
- Herbst Instructions
- All About the FACEMASK
- Brushing and Flossing
- Extra Care
- Patient Care Videos
Accelerated Treatment
Careers
Contact Us
Free Consultation – LP
Blog
About Us
Privacy Policy
Free Consultation – Thank You
Meet Dr. Melissa Kornhaber
Meet Dr. Inna Gellerman
The Gellerman Method
Community Involvement

Homepage
Palatal Expansion (MARPE)
20 Years of Smiles
Calculate Payments
Payment Calculator
How to Fix an Overbite, Increase Airway Volume, and Improve Your Appearance with One Appliance
Hometown Hero Contest
Hometown Hero – Thank You
Current Patient Virtual Consultation
Free Virtual Consultation
Online Smile Assessment
Homepage
Headache Relief
TMJ-TMD Treatment In Huntington, NY
Sleep and Wellness at Gellerman Orthodontics
Integrative Orthodontics In Huntington, NY
Sleep Apnea Treatment In Huntington, NY
Surgical Treatment
Two-Phase Treatment
Board Certification
Patient Form
Mouthguard Program
Our Dream Team
Suresmile Huntington, NY
Contact Us – Thank You
Orthodontist or Dentist?
What Sets Us Apart
Español
Patient Resources
- New Patient Forms
- Your First Visit
- Payment Plans
- Life with Braces
- Retainer Appliance
- Palatal Expander
- Herbst Instructions
- All About the FACEMASK
- Brushing and Flossing
- Extra Care
- Patient Care Videos
Accelerated Treatment
Careers
Contact Us
Free Consultation – LP
Blog
About Us
Privacy Policy
Free Consultation – Thank You
Meet Dr. Melissa Kornhaber
Meet Dr. Inna Gellerman
The Gellerman Method
Community Involvement

About
Invisalign
Braces
Treatments
Resources
Contact Us
Blog
Español
Patient Portal