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 NameLast NameDate of BirthGender?MaleFemaleHome NumberPrimary Phone NumberEmail Address AddressCityStreetStatePostcodeEmergency Contact DetailsFull NamePrimary Phone NumberPatient InformationDo you have private health insurance?Do you have private health insurance?YesNoFund NameDo you have Dental Extras Cover?Do you have Dental Extras Cover?YesNoCard NumberHave you been to this practice before?Have you been to this practice before?YesNoHave any of the patients relatives attended our surgery?Have any of the patients relatives attended our surgery?YesNoName of RelativeHow did you hear about our practice?Referred by a friendGoogleWebsiteFacebookInstagramMagazine adOtherWhich Magazine?Please specifyWho 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?YesNoPlease give detailsIs the patient currently on any medications?Is the patient currently on any medications?YesNoPlease list hereHas the patient ever been hospitalised?Has the patient ever been hospitalised?YesNoPlease give detailsHas the patient had their tonsils/adenoids removed?Has the patient had their tonsils/adenoids removed?YesNoPlease give detailsDoes the patient have any physical or mental impairments?Does the patient have any physical or mental impairments?YesNoPlease give detailsDo you suffer from any of the following:Heart/Vascular DisorderHeart/Vascular DisorderYesNoBlood Disease/BleederBlood Disease/BleederYesNoBlood PressureBlood PressureYesNoRheumatic FeverRheumatic FeverYesNoArthritisArthritisYesNoDiabetesDiabetesYesNoDiabetesDiabetesYesNoLiver or Kidney DiseaseLiver or Kidney DiseaseYesNoAsthmaAsthmaYesNoEpilepsyEpilepsyYesNoCold SoresCold SoresYesNoHepatitis or HIVHepatitis or HIVYesNoAllergy/HypersensitivityAllergy/HypersensitivityYesNoAre you pregnantAre you pregnantYesNoOther (please give details):Has the patient ever received speech therapy?Has the patient ever received speech therapy?YesNoPlease give detailsDoes 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?YesNoPlease give detailsDoes the patient clench or grind their teeth?Does the patient clench or grind their teeth?YesNoPlease give detailsDoes 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?YesNoPlease give detailsPERSON RESPONSIBLE FOR ACCOUNT:Last NameFirst NameAddressHome NumberMobile NumberEmail SECOND PERSON RESPONSIBLE FOR ACCOUNT (if applicable):Last NameFirst NameAddressHome NumberMobile NumberEmail 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 responsibleYesNoIf yes, whoDue 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, modelsYesNoSignature (18 and above)DateFor 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 SignatureDateGuardian SignatureDateCAPTCHA
