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. Patient InformationTitle Name First Last Preferred Name Date of Birth Day Month Year Contact No.AgeGenderMaleFemaleOccupation / School Home Address Email Address (Parent / Guardian)* Emergency Contact DetailsName First Last Contact No.Relationship Account InformationIs the patient responsible for the account? Yes No Title Name First Last Relationship Contact No.Home Address Email Address Referral and Health Insurance InformationDoes the patient have private health insurance? Yes No If so, Fund name Has the patient had a previous orthodontic assessment?? Yes No Does the patient have siblings or family members who also attend this practice (please provide their name/s)? How did you hear about our practice? Who can we thank for your referral? Who is your Dentist? Who is your GP? Health InformationPlease tick if the following is appropriate to the Patient? Heart/Vascular Disorder Blood Disease/Bleeder Blood Pressure Rheumatic Fever Arthritis Diabetes Liver or kidney disease Asthma Epilepsy Cold Sores Hepatitis or HIV Allergy/Hypersensitivity Pregnant Requires antibiotic cover for dental procedure (Typically for known heart conditions) Had Tonsils/adenoids removed Ever received speech therapy Any habits such as finger or thumb sucking Any special needs (e.g., sensory, autism, anxiety) Currently on any medications Other High / Low If stopped, at what age? Any special needs (e.g., sensory, autism, anxiety) Currently on any medications Other Consent and DisclosureI consent to having the following: x-rays, models and photographs published for continuing education purposes or on the web? I consent to having the following: x-rays, models and photographs published for continuing education purposes or on the web?I certify that the above medical and personal information is accurate currently. If there are future changes, I will inform this office* I certify that the above medical and personal information is accurate currently. If there are future changes, I will inform this office*Signature Date Day Month Year CAPTCHA
