Welcome to the Orthodontist

Welcome to Suliman Orthodontics
1. About You
Today's Date
E-mail*
Name*

PrefixFirst NameMiddle NameLast Name
I prefer to be called:
MaleFemale
Date of Birth

MonthDayYear
Age
SS#
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Marital Status

SingleMarriedDivorcedWidowedSeparated
Home Phone #

Area CodePhone Number
Cell Phone/Other #

Area CodePhone Number
Work Phone #

Area CodePhone Number
Driver's Licence
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
How Long There?
Where & When are best times to reach you?
Whom may we thank you for referring you to our office?
Other Family Members Seen by Us
General Dentist
Date of Last Visit

MonthDayYear
Date
2. Spouse Information
His/Her Name

First NameLast Name
Employer
Work Phone #

Area CodePhone Number
Ext.:
Social Security #
Cell Phone #

Area CodePhone Number
Birthdate
Peron Responsible for Account
Work Phone #

Area CodePhone Number
Ext.:
Home Phone #

Area CodePhone Number
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relation
Social Security #
Employer
Drivers License
3. Orthodontic Insurance
Primary
Orthodontic Coverage

YesNo
Dental Coverage

YesNo
Insurance Company Name
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group # (Plan, Local or Policy #)
Insured Name
Relation
Insured Birthdate

MonthDayYear
Date
Insured ID #
Insured Employer Name
Secondary
Orthodontic Coverage

YesNo
Dental Coverage

YesNo
Insurance Company Name
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group # (Plan, Local or Policy #)
Insured Name
Relation
Insured Birthdate

MonthDayYear
Date
Insured ID #
Insured's Employer
In the event of an emergency, is there someone who lives near you that we should contact?
His/Her Name

First NameLast Name
Relation
Work #

Area CodePhone Number
Home #

Area CodePhone Number
4. Medical History
Do you have a personal physician?

YesNo
Physician Name
Date of Last Visit

MonthDayYear
Date
Phone Number

Area CodePhone Number
Please describe your physical health

GoodFairPoor
Are you currently under the care of a physician?

YesNo
Please Explain:
Are you taking any prescription / over the counter drugs?

YesNo
Please list all medications that you are currently taking:
For Women:
Are you using a prescribed method of birth control?

YesNo
Are you pregnant?

YesNo
If yes, how many weeks?
Are you nursing?

YesNo
Have you ever had any of the following diseases or medical problems?
Abnormal Bleeding*

YesNo
Anemia*

YesNo
Artificial Bones/Joints/Valves*

YesNo
Asthma / Arthritis*

YesNo
Blood Transfusion*

YesNo
Cancer/Chemotherapy*

YesNo
Congenital Heart Defect*

YesNo
Diabetes*

YesNo
Difficulty Breathing*

YesNo
Drug/Alcohol Abuse*

YesNo
Emphysema*

YesNo
Epilepsy/Seizures/Fainting*

YesNo
Fever Blisters/Herpes*

YesNo
Glaucoma*

YesNo
Heart Attack/Stroke*

YesNo
Heart Murmur*

YesNo
Heart Surgery/Pacemaker*

YesNo
Hemophilia*

YesNo
Hepatitis*

YesNo
High/Low Blood Pressure*

YesNo
HIV +/AIDS*

YesNo
Hospitalized for Any Reason*

YesNo
Kidney Problems*

YesNo
Mitral Valve Prolapse*

YesNo
Psychiatric Problems*

YesNo
Radiation Treatment*

YesNo
Rheumatic/Scarlet Fever*

YesNo
Severe/Frequent Headaches*

YesNo
Shingles*

YesNo
Sickle Cell Disease/Traits*

YesNo
Sinus Problems*

YesNo
Tuberculosis (TB)*

YesNo
Ulcers/Colitis*

YesNo
Venereal Disease*

YesNo
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following?
Aspirin*

YesNo
Any Metals/Plastic*

YesNo
Codeine*

YesNo
Dental Anesthetics*

YesNo
Erythromycin*

YesNo
Latex*

YesNo
Penicillin*

YesNo
Tetracycline*

YesNo
Other*

YesNo
Please list any other drugs/materials that you are allergic to:
5. Dental History
What are the main concerns you would like orthodontics to address?
Have you ever been evaluated for orthodontic treatment before?

YesNo
Have you ever had a serious/difficult problem associated with any previous dental work?

YesNo
Do you now or have you ever experienced pain/discomfort in your jaw joint? (TMJ, TMD)?*

YesNo
Do you like your smile?*

YesNo
Your current dental heallth is:*

GoodFairPoor
Gums ever bleed?*

YesNo
Have you ever had an injury to your:*

MouthTeethChin
Do you have any speech problems?
Do you generally breathe through your mouth?

YesNo
Do you have any missing or extra permanent teeth?

YesNo
Have you ever taken Fosamax, or any other bisphosponate?*

YesNo
Have you ever taken Phen-Fen?*

YesNo
Do you smoke or use tobacco in any form?*

YesNo
Agree to Terms

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in patient's medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
I Agree to the above terms and conditions*

Yes
Thank you for filling out this form completely.
This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.
Signature

Clear
Date
If this office accepts insurance, I understand that I am responsible for the payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.
Signature

Clear
Date
Initials
Should be Empty:

Welcome to Suliman Orthodontics

1. About You

2. Spouse Information

3. Orthodontic Insurance

4. Medical History

5. Dental History