• Welcome to Suliman Orthodontics

  • 1. About You

  • Marital Status
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  • Date of Last Visit
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    2 digit month, 2 digit day, 4 digit year

  • 2. Spouse Information

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  • 3. Orthodontic Insurance

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    Primary

  • Orthodontic Coverage
  • Dental Coverage
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  • Insured Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year

  • Secondary

  • Orthodontic Coverage
  • Dental Coverage
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  • Insured Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year

  • In the event of an emergency, is there someone who lives near you that we should contact?

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  • 4. Medical History

  • Do you have a personal physician?
  • Date of Last Visit
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    2 digit month, 2 digit day, 4 digit year
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  • Please describe your physical health
  • Are you currently under the care of a physician?
  • Are you taking any prescription / over the counter drugs?

  • For Women:

  • Are you using a prescribed method of birth control?
  • Are you pregnant?
  • Are you nursing?

  • Have you ever had any of the following diseases or medical problems?

  • Abnormal Bleeding*
  • Anemia*
  • Artificial Bones/Joints/Valves*
  • Asthma / Arthritis*
  • Blood Transfusion*
  • Cancer/Chemotherapy*
  • Congenital Heart Defect*
  • Diabetes*
  • Difficulty Breathing*
  • Drug/Alcohol Abuse*
  • Emphysema*
  • Epilepsy/Seizures/Fainting*
  • Fever Blisters/Herpes*
  • Glaucoma*
  • Heart Attack/Stroke*
  • Heart Murmur*
  • Heart Surgery/Pacemaker*
  • Hemophilia*
  • Hepatitis*
  • High/Low Blood Pressure*
  • HIV +/AIDS*
  • Hospitalized for Any Reason*
  • Kidney Problems*
  • Mitral Valve Prolapse*
  • Psychiatric Problems*
  • Radiation Treatment*
  • Rheumatic/Scarlet Fever*
  • Severe/Frequent Headaches*
  • Shingles*
  • Sickle Cell Disease/Traits*
  • Sinus Problems*
  • Tuberculosis (TB)*
  • Ulcers/Colitis*
  • Venereal Disease*

  • Are you allergic to any of the following?

  • Aspirin*
  • Any Metals/Plastic*
  • Codeine*
  • Dental Anesthetics*
  • Erythromycin*
  • Latex*
  • Penicillin*
  • Tetracycline*
  • Other*

  • 5. Dental History

  • Have you ever been evaluated for orthodontic treatment before?
  • Have you ever had a serious/difficult problem associated with any previous dental work?
  • Do you now or have you ever experienced pain/discomfort in your jaw joint? (TMJ, TMD)?*
  • Do you like your smile?*
  • Your current dental heallth is:*
  • Gums ever bleed?*
  • Have you ever had an injury to your:*
  • Do you generally breathe through your mouth?
  • Do you have any missing or extra permanent teeth?
  • Have you ever taken Fosamax, or any other bisphosponate?*
  • Have you ever taken Phen-Fen?*
  • Do you smoke or use tobacco in any form?*

  • 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.

  • 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.

  • 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.

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