Dr.Orthodontics
Amal Kharbouch
Murphy
Orthodontics
Murphy
!"#$%$&'$())$*+,-.$/$0$'+12345$67$8(9#)$:::$;3<$=")0$#)(0)9)9$0$&>?<$#8=0$@@"0@""9$
!"#$%$&'$())$*+,-.$/$0$'+12345$67$8(9#)$:::$;3<$=")0$#)(0)9)9$0$&>?<$#8=0$@@"0@""9$
'.A,B>C$D.E->C$F,G-H14$&H1I$JH1$/A+C-$;>-,.E-G$
'.A,B>C$D.E->C$F,G-H14$&H1I$JH1$/A+C-$;>-,.E-G$
;>-,.E-$ ;>-,.E-$
D>-.$KKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
D>-.$KKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
;>-,.E-LG$C>G-$E>I.$KKKKKKKKKKKKKKKKKKKKKKKKK$&,1G-$E>I.$KKKKKKKKKKKKKKKKKKKKKKKKKK',AAC.$,E,-,>CKKKKKKKKK$
;>-,.E-LG$C>G-$E>I.$KKKKKKKKKKKKKKKKKKKKKKKKK$&,1G-$E>I.$KKKKKKKKKKKKKKKKKKKKKKKKKK',AAC.$,E,-,>CKKKKKKKKK$
6,-C.$'1M$'1GM$'GM$',GGM$D1M$N-3.1$KKKKKKKKKKKKKKKKKK$O$21.J.1$-H$P.$B>CC.A$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
6,-C.$'1M$'1GM$'GM$',GGM$D1M$N-3.1$KKKKKKKKKKKKKKKKKK$O$21.J.1$-H$P.$B>CC.A$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
Q,1-3$A>-.$KKKKKK0KKKKKK0KKKKKKKKKK$*.?$'>C.$&.I>C.$*HB,>C$*.B+1,-4$R
$KKKKKKKK0KKKKKKKK0KKKKKKKK$
Q,1-3$A>-.$KKKKKK0KKKKKK0KKKKKKKKKK$*.?$'>C.$&.I>C.$*HB,>C$*.B+1,-4$R
$KKKKKKKK0KKKKKKKK0KKKKKKKK$
'>1,->C$*->-+G<$$*,ESC.5$'>11,.A5$*.2>1>-.A5$D,TH1B.A5$%,AHU.AM$
'>1,->C$*->-+G<$$*,ESC.5$'>11,.A5$*.2>1>-.A5$D,TH1B.A5$%,AHU.AM$
FHI.$>AA1.GG$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$V,-4KKKKKKKKKKKKKKKKKKK$*->-.$KKKKKW,2$BHA.$KKKKKKKK$
FHI.$>AA1.GG$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$V,-4KKKKKKKKKKKKKKKKKKK$*->-.$KKKKKW,2$BHA.$KKKKKKKK$
FHI.$23HE.$XKKKKKY$KKKKKK0KKKKKK$V.CC$23HE.$XKKKKKY$KKKKK0KKKKKK$%H1Z$23HE.$XKKKKKKY$KKKKKK0KKKKKK$
FHI.$23HE.$XKKKKKY$KKKKKK0KKKKKK$V.CC$23HE.$XKKKKKY$KKKKK0KKKKKK$%H1Z$23HE.$XKKKKKKY$KKKKKK0KKKKKK$
[I>,C$/AA1.GG<$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
[I>,C$/AA1.GG<$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
NBB+2>-,HE$KKKKKKKKKKKKKKKKKKK$[I2CH4.1$KKKKKKKKKKKKKKKKKKKKKK$
NBB+2>-,HE$KKKKKKKKKKKKKKKKKKK$[I2CH4.1$KKKKKKKKKKKKKKKKKKKKKK$
CHG.G-$\.C>-,T.$
VCHG.G-$\V.C>-,T.$
VCHG.G-$\.C>-,T.<$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
VCHG.G-$\.C>-,T.<$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
*2H+G.$E>I.XGYKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK6,-C.$'1M$'1GM$'GM$',GGM$D1M$N-3.1$KKKKKKKKKKKKKK$$
*2H+G.$E>I.XGYKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK6,-C.$'1M$'1GM$'GM$',GGM$D1M$N-3.1$KKKKKKKKKKKKKK$$
\.C>-,HEG3,2$-H$2>-,.E-KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
\.C>-,HEG3,2$-H$2>-,.E-KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
/AA1.GG$!"#$%"##&'&()$)*+($,+)"&()$+%%'&--.$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
/AA1.GG$!"#$%"##&'&()$)*+($,+)"&()$+%%'&--.$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
FHI.$;3HE.$!/#$%"##&'&().$XKKKKKKY$KKKKKK0KKKKKK$V.CC$23HE.$XKKKKKY$KKKKK0KKKKK$%H1Z$23HE.$XKKKKKY$KKKKK0KKKKKK$
FHI.$;3HE.$!/#$%"##&'&().$XKKKKKKY$KKKKKK0KKKKKK$V.CC$23HE.$XKKKKKY$KKKKK0KKKKK$%H1Z$23HE.$XKKKKKY$KKKKK0KKKKKK$
D.E-,G-$ D.E-,G-$
;>-,.E-LG$D.E-,G-$/AA1.GG$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK5$V,-45$KKKKKKKKKKKKKKKKKKKKKK*->-.KKKKKKK$W,2$KKKKKKKKKK$
;>-,.E-LG$D.E-,G-$/AA1.GG$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK5$V,-45$KKKKKKKKKKKKKKKKKKKKKK*->-.KKKKKKK$W,2$KKKKKKKKKK$
]>G-$G..E$KKKKKKKKKKKKKKKKKKKKKK$\.>GHE$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$^.?-$>22H,E-I.E-$KKKKKKKKKKKKKKKKK$
]>G-$G..E$KKKKKKKKKKKKKKKKKKKKKK$\.>GHE$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$^.?-$>22H,E-I.E-$KKKKKKKKKKKKKKKKK$
N-3.1$A.E-,G-G_A.E->C$G2.B,>C,G-G$EHU$P.,ES$G..E<$^>I.KKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$V,-45$*->-.$KKKKKKKKKKKKKKKKKKKKKKKK$
N-3.1$A.E-,G-G_A.E->C$G2.B,>C,G-G$EHU$P.,ES$G..E<$^>I.KKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$V,-45$*->-.$KKKKKKKKKKKKKKKKKKKKKKKK$
\.>GHEKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
\.>GHEKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
;34G,B,>E$
;34G,B,>E$
;>-,.E-LG$;34G,B,>E$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$V,-45$*->-.KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
;>-,.E-LG$;34G,B,>E$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$V,-45$*->-.KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
]>G-$G..E$KKKKKKKKKKKKKKKKKKKKKKKK\.>GHE$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$^.?-$>22H,E-I.E-$KKKKKKKKKKKK$
]>G-$G..E$KKKKKKKKKKKKKKKKKKKKKKKK\.>GHE$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$^.?-$>22H,E-I.E-$KKKKKKKKKKKK$
'HG-$1.B.E-$234G,B>C$.?>I$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
'HG-$1.B.E-$234G,B>C$.?>I$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
N-3.1$234G,B,>EG_3.>C-3$B>1.$21HT,A.1G$P.,ES$G..E$EHU<$
N-3.1$234G,B,>EG_3.>C-3$B>1.$21HT,A.1G$P.,ES$G..E$EHU<$
^>I.KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$V,-45$*->-.KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
^>I.KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$V,-45$*->-.KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
\.>GHE$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
\.>GHE$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
^>I.KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$V,-45$*->-.KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
^>I.KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$V,-45$*->-.KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
\.>GHE$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
\.>GHE$KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK$
214 945 4040
619 W. FM 544
Suite A
Murphy, Texas 75094
www.MurphyOrthodontics.net
Financial Responsibility
Who is financially responsible for this account? ______________________________________________________________________ Address (if different than page 1) _________________________________________ City, State, Zip_______________________________ Home phone ( ) _______-­‐_________ Cell phone ( ) _______-­‐_________ Email address _____________________________________ Social Security #__________-­‐___________-­‐_______________ Employer ______________________________________________ Who will be responsible for bringing the patient to orthodontic appointments? ______________________________________________ Dental Insurance
Primary policy holder’s full name _______________________________________________________ Birth date _________________ Social Security #____________________________________ Relationship to patient_______________________________________ Address and phone (if not listed above) ____________________________________________________________________________ Employer________________________________ Address___________________________________________________________ Insurance company_________________________ Group # ________________________ ID# _______________________________ Does this policy have orthodontic benefits? □Yes □ No □ Don’t Know. Secondary policy holder’s full name _____________________________________________________ Birth date _________________ Social Security #__________-­‐___________-­‐_____________ Relationship to patient______________________________________ Address and phone (if not listed above) ____________________________________________________________________________ Employer_______________________________ Address _____________________________________________________________ Insurance company_______________________________ Group # _________________ ID# ___________________________________________ Does this policy have orthodontic benefits? Yes No Don’t Know Medical Insurance
Policy holder’s full name _______________________________________________________________________________________ Insurance Company ___________________________________________________________________________________________ Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete □□
orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u).
Medical History Now or in the past, has your child had: Yes No DK/U □ □ □ Birth defects or hereditary problems? □ □ □ Bone fractures or major injuries? □ □ □ Any injuries to face, head, neck? □ □ □ Arthritis or joint problems? □ □ □ Cancer, tumor, radiation treatment or chemotherapy? □ □ □ Endocrine or thyroid problems? □ □ □ Diabetes or low sugar? □ □ □ Kidney problems? □ □ □ Immune system problems? □ □ □ History of osteoporosis? □ □ □ Gonorrhea, syphilis, herpes, sexually transmitted diseases? □ □ □ AIDS or HIV positive? □ □ □ Hepatitis, jaundice, or other liver problems? □ □ □ Polio, mononucleosis, tuberculosis, pneumonia? □ □ □ Seizures, fainting spells, neurologic problems? □ □ □ Mental health disturbance or depression? □ □ □ History of eating disorder (anorexia, bulimia)? □ □ □ Frequent headaches or migraines? □ □ □ High or low blood pressure? □ □ □ Excessive bleeding or bruising, anemia? □ □ □ Chest pain, shortness of breath, tire easily, swollen ankles? □ □ □ Heart defects, heart murmur, rheumatic heart disease? □ □ □ Angina, arteriosclerosis, stroke or heart attack? □ □ □ Skin disorder (other than common acne)? □ □ □ Does your child eat a well-­‐balanced diet? □ □ □ Vision, hearing, or speech problems? □ □ □ Frequent ear infections, colds, throat infections? □ □ □ Asthma, sinus problems, hay fever? □ □ □ Tonsil or adenoid condition? Yes No DK/U □ □ □ Does your child frequently breathe through his/her mouth? □ □ □ Has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer? □ □ □ Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel(ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders? Has your child had allergies or reactions to any of the following? Yes No DK/U □ □ □ Local anesthetics (novocaine, lidocaine, xylocaine) □ □ □ Latex (gloves, balloons) □ □ □ Aspirin □ □ □ Ibuprofen (Motrin, Advil) □ □ □ Penicillin □ □ □ Other antibiotics □ □ □ Metals (jewelry, clothing snaps) □ □ □ Acrylics □ □ □ Plant pollens □ □ □ Animals □ □ □ Foods □ □ □ Other substances _________________________________ Dental History Now or in the past, has your child had: Yes No DK/U □ □ □ Erupting teeth very early or very late? □ □ □ Primary (baby) teeth removed that were not loose? □ □ □ Permanent or extra (supernumerary) teeth removed? □ □ □ Supernumerary (extra) or congenitally missing teeth? □ □ □ Chipped or injured primary or permanent teeth? □ □ □ Any sensitive or sore teeth? □ □ □ Any lost or broken fillings? □ □ □ Jaw fractures, cysts, infections? □ □ □ Any teeth treated with root canals or pulpotomies? □ □ □ Frequent canker sores or cold sores? □ □ □ History of speech problems or speech therapy? □ □ □ Difficulty breathing through nose? □ □ □ Mouth breathing habit or snoring at night? □ □ □ History of speech problems? □ □ □ Frequent oral habits (sucking finger, chewing pen, etc)? □ □ □ Teeth causing irritation to lip, cheek or gums? □ □ □ Tooth grinding or clenching? □ □ □ Clicking, locking in jaw joints? □ □ □ Soreness in jaw muscles or face muscles? □ □ □ Has your child been treated for “TMJ” or “TMD” problems? □ □ □ Any broken or missing fillings? □ □ □ Any serious trouble associated with previous dental treatment? □ □ □ Has your child ever been diagnosed with gum disease or pyorrhea?