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Stars Orthodontics

239B Argyle Avenue

613-232-4266

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Stars Orthodontics

Dr. Khaled A. Sharaf

B.Sc., DMD, MBA, M.Sc., FRCD(C) | Certified Specialist in Orthodontics

Last Name:

First Name:

Gender:

Male

Female

Other

Age:

Date of Birth (mm/dd/yyyy):

Occupation:

Home Address:

City:

Province:

Postal Code:

Home Phone:

Cell Phone:

Email:

Work Phone:

Person Responsible for Account:

Do you have dental insurance?

Yes

No

Unsure

If yes, please provide:

Policy Holder's Name:

Name of Insurance Company:

Group/Policy/Plan Number:

Policy Holder's Date of Birth (mm/dd/yyyy):

ID or Certificate Number:

Are you covered by any other dental insurance?

Yes

No

Unsure

If yes, please provide:

Policy Holder's Name:

Name of Insurance Company:

Group/Policy/Plan Number:

Policy Holder's Date of Birth (mm/dd/yyyy):

ID or Certificate Number:

Family Dentist:

Family Physician:

Date of last visit (mm/dd/yyyy):

Whom may we thank for referring you?

What is the reason for your visit?

Medical History

Are you in good health?

Yes

No

Have you had any serious illnesses/hospitalizations?

Yes

No

Do you currently have or have you been treated for any of the following:

If you checked any of the above, please give details:

List any medications now being taken:

List any drug allergies or sensitivities:

Do you smoke or chew tobacco? How often?

WOMEN: Are you pregnant?

Yes

No

Unsure

Dental History

Have you ever had any injuries to the face, mouth or teeth?

Yes

No

Have you ever been treated for a jaw joint problem, including surgery?

Yes

No

Have you ever sucked your thumb or finger? Until what age?

Yes

No

Do you have any speech problems?

Yes

No

Do you have any habits (nail biting, lip biting)?

Yes

No

Do you have frequent canker or cold sores?

Yes

No

Are you a mouth breather? While asleep? While awake?

Yes

No

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

Yes

No

Do you grind or clench your teeth?

Yes

No

Do you have difficulty opening and/or closing your jaw?

Yes

No

Have you ever had a previous orthodontic examination?

Yes

No

Are you apprehensive towards dental visits?

Yes

No

Have any other family members had braces or orthodontic treatment?

Yes

No

How often do you brush your teeth?

How often do you floss?

For Adults

Patient Biographical Information

For Children

Patient Biographical Information

Last Name:

First Name:

Date of Birth (mm/dd/yyyy):

School:

Gender:

Male

Female

Other

Age:

Grade:

List any sports, hobbies or musical instruments:

What is the reason for your visit?

Home Address:

City:

Province:

Postal Code:

Home Phone:

Email

Parent/Guardian 1:

First Name:

Last Name:

Address same as patient

Home Address:

City:

Province:

Postal Code:

Home Phone:

Cell Phone:

Work Phone:

If parent/guardian has dental insurance, please provide:

Name of Insurance Company:

Group/Policy/Plan Number:

Date of Birth (mm/dd/yyyy):

ID or Certificate Number:

Parent/Guardian 2:

First Name:

Last Name:

Address same as patient

Home Address:

City:

Province:

Postal Code:

Home Phone:

Cell Phone:

Work Phone:

If P/G 2 has dental insurance, please provide:

Name of Insurance Company:

Group/Policy/Plan Number:

Date of Birth (mm/dd/yyyy):

ID or Certificate Number:

Parent/Guardian 3:

First Name:

Last Name:

Address same as patient

Home Address:

City:

Province:

Postal Code:

Home Phone:

Cell Phone:

Work Phone:

If P/G 3 has dental insurance, please provide:

Name of Insurance Company:

Group/Policy/Plan Number:

Date of Birth (mm/dd/yyyy):

ID or Certificate Number:

Parent/Guardian 4:

First Name:

Last Name:

Address same as patient

Home Address:

City:

Province:

Postal Code:

Home Phone:

Cell Phone:

Work Phone:

If P/G 4 has dental insurance, please provide:

Name of Insurance Company:

Group/Policy/Plan Number:

Date of Birth (mm/dd/yyyy):

ID or Certificate Number:

Person(s) Responsible for Account:

Family Dentist:

Family Physician:

Date of last visit:

Whom may we thank for referring you?

Medical History

Is your child in good health?

Yes

No

Has your child had any serious illnesses/hospitalizations?

Yes

No

Does your child currently have or have they been treated for any of the following:

If you checked any of the above, please give details:

List any medications now being taken:

List any drug allergies or sensitivities:

Have the tonsils or adenoids been removed? At what age?

Has the patient reached puberty?

Yes

No

Girls: Has menstruation started?

Yes

No

Boys: Has voice changed yet?

Yes

No

Dental History

Has your child ever had any injuries to the face, mouth or teeth?

Yes

No

Has your child ever been treated for a jaw joint problem, including surgery?

Yes

No

Does your child have any speech problems?

Yes

No

Does your child have any habit (nail biting, lip biting)?

Yes

No

Is your child a mouth breather? While asleep? While awake?

Yes

No

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

Yes

No

Is your child apprehensive towards dental visits?

Yes

No

Does your child want orthodontic treatment?

Yes

No

How often does your child brush his/her teeth?

How often does he/she floss?

Has your child ever sucked his/her thumb or finger? Until what age?

Yes

No

Does your child have frequent canker or cold sores?

Yes

No

Has your child ever had a previous orthodontic examination?

Yes

No

Have any other family members had braces or orthodontic treatment?

Yes

No

Contact Us

Stars Orthodontics

Dr. Khaled Sharaf

239B Argyle Avenue

Ottawa, ON K2P 1B8

613-232-8864

info@starsortho.ca

Service Area

Ottawa

Office Hours:

Monday - Thursday

08:30 AM - 04:30 PM

Friday

By appointment only

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