• Welcome to Suliman Orthodontics

  • We would like to welcome you and your child to our office. Our goal is to make every child's visit pleasant and educational. We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.  

  • 1. Tell Us About Your Child

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  • 2. Who is Accompanying Your Child Today?

  • Do you have legal custody of this child?
  • Parent's Marital Status:

  • 3. Parent's Information

  • Parent:
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  • Parent:
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  • 4. Person Responsible For Account

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  • Who is responsible for making appointments?

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  • 5. Orthodontic Insurance

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    Primary

  • Orthodontic Coverage
  • Dental Coverage
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  • Policy Owner's Birthdate
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    2 digit month, 2 digit day, 4 digit year

  • Secondary

  • Orthodontic Coverage
  • Dental Coverage
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  • Policy's Owner's Birthdate
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    2 digit month, 2 digit day, 4 digit year

  • 6. Orthodontic History

  • Has your child ever been evaluated or had orthodontic treatment before?
  • Have there been any injuries to the face, mouth, teeth or chin?*
  • Have adenoids or tonsils been removed?*
  • Has your child been informed of any missing or extra permanent teeth?
  • Has your child ever had pain/tenderness in his/her jaw joint? (TMJ, TMD)?*
  • Does your child brush his/her teeth daily?*
  • Does your child floss his/her teeth daily?
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  • Date of Last Visit
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    2 digit month, 2 digit day, 4 digit year
  • Is your child currently under the care of a physician?
  • Has puberty begun?
  • Has menstruation begun? (girls)
  • Have you ever taken Fosamax, or any other bisphosponate?*
  • Please describe your physical health

  • 7. Has your child ever had any of the following medical problems?

  • Abnormal Bleeding*
  • ADD/ADHD*
  • Allergies to any Drugs*
  • Allergies to Latex/Metals*
  • Allergies to Plastic*
  • Any Hospital Stays*
  • Any Operations*
  • Artificial Bones/Joints/Valves*
  • Asperger Syndrome*
  • Asthma*
  • Autism*
  • Cancer*
  • Congenital Heart Defect*
  • Convulsions/Epilepsy*
  • Diabetes*
  • Handicaps/Disabilities*
  • Hearing Impairment*
  • Heart Murmur*
  • Hemophilia*
  • Hepatitis*
  • HIV +/AIDS*
  • Kidney Problems*
  • Liver Problems*
  • Lupus*
  • Rheumatic/Scarlet Fever*
  • Sickle Cell Disease/Traits*
  • Tuberculosis (TB)*

  • 8. Does/Did your child have any of the following habits?

  • Clenching/Grinding Teeth
  • Lip Sucking/Biting
  • Mouth Breather
  • Nail Biting
  • Nursing Bottle
  • Speech Problems
  • Thumb/Finger Sucking
  • Tongue Thrust

  • A neighbor or relative not living with you.

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  • Agree to Terms

    I understand that the information I have given today is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need. If this office accepts insurance, I assign directly to Dr Suliman. all insurance benefits otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover.  I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

  • 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.

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