Submitting the form below lets us get to know you a little better. Having this information allows us to provide you with the best personalised treatment options. First Name Last Name Date of Birth Gender?MaleFemaleHome Number Primary Phone Number Email Address AddressCity Street State Postcode Emergency Contact DetailsFull Name Primary Phone Number Patient InformationDo you have private health insurance?Do you have private health insurance? Yes No Fund Name Do you have Dental Extras Cover?Do you have Dental Extras Cover? Yes No Card Number Have you been to this practice before?Have you been to this practice before? Yes No Have any of the patients relatives attended our surgery?Have any of the patients relatives attended our surgery? Yes No Name of Relative How did you hear about our practice?Referred by a friendGoogleWebsiteFacebookInstagramMagazine adOtherWhich Magazine? Please specify Who can we thank for your referral? Who is your Dentist? Who is your Doctor? Name of School (if applicable) What are your main reasons for seeking orthodontic treatment?Medical HistoryHas there been any major changes in the patients health recently?Has there been any major changes in the patients health recently? Yes No Please give details Is the patient currently on any medications?Is the patient currently on any medications? Yes No Please list here Has the patient ever been hospitalised?Has the patient ever been hospitalised? Yes No Please give details Has the patient had their tonsils/adenoids removed?Has the patient had their tonsils/adenoids removed? Yes No Please give details Does the patient have any physical or mental impairments?Does the patient have any physical or mental impairments? Yes No Please give details Do you suffer from any of the following:Heart/Vascular DisorderHeart/Vascular Disorder Yes No Blood Disease/BleederBlood Disease/Bleeder Yes No Blood PressureBlood Pressure Yes No Rheumatic FeverRheumatic Fever Yes No ArthritisArthritis Yes No DiabetesDiabetes Yes No DiabetesDiabetes Yes No Liver or Kidney DiseaseLiver or Kidney Disease Yes No AsthmaAsthma Yes No EpilepsyEpilepsy Yes No Cold SoresCold Sores Yes No Hepatitis or HIVHepatitis or HIV Yes No Allergy/HypersensitivityAllergy/Hypersensitivity Yes No Are you pregnantAre you pregnant Yes No Other (please give details):Has the patient ever received speech therapy?Has the patient ever received speech therapy? Yes No Please give details Does the patient have any habits such as finger or thumb sucking? If stopped, at what age?Does the patient have any habits such as finger or thumb sucking? Yes No Please give details Does the patient clench or grind their teeth?Does the patient clench or grind their teeth? Yes No Please give details Does the patient suffer from any jaw dysfunction such as jaw pain, clicking, popping, locking or ringing in the ears?Does the patient suffer from any jaw dysfunction such as jaw pain, clicking, popping, locking or ringing in the ears? Yes No Please give details PERSON RESPONSIBLE FOR ACCOUNT:Last Name First Name Address Home Number Mobile Number Email SECOND PERSON RESPONSIBLE FOR ACCOUNT (if applicable):Last Name First Name Address Home Number Mobile Number Email Parent’s Marital status:MarriedSeparatedDivorcedWidowedIf only one person has been specified to be responsible for the account, do you give permission for Specialty Orthodontics to discuss the account with another involved paying party or parent?If only one person has been specified to be responsible Yes No If yes, who Due to privacy laws,Specialty Orthodontics will not disclose any financial information to any person who is not named on this account information form.I consent to having my x-rays, models and photographs published for continuing education purposes or on the webI consent to having my x-rays, models Yes No Signature (18 and above) Date For Parents/GuardiansI certify that the above medical and personal information is accurate at this time. If there are future changes, I will inform this office. I also authorise this office to explore and initiate necessary dental services in the case of a minor patient.Parent Signature Date Guardian Signature Date CAPTCHA
