New Patient Enrollment Form

PATIENT DETAILS
(To be completed by a Parent/Guardian if the patient is under 18 years of age)
To provide you with the highest standard of orthodontic care, it is essential to know your medical and dental history, as these factors may impact the success of your treatment. If you have any questions regarding the information we collect from you and hold in your records, please do not hesitate to ask us. We are acting in your best interest at all times. Please read our privacy policy for further information.
PATIENT DETAILS
Title*
Name*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postcode
Date of Birth*

DayMonthYear
Date
Gender*
School (if applicable)
E-mail*
example@example.com
RESPONSIBLE PARTY
Name of person completing this form*
Relationship to patient*
Signature*

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Date*

MonthDayYear
HOW DID YOU HEAR ABOUT US?
Name/s of any other family members who have attended the practice?
What is your main reason for seeking this consultation?
Whom may we thank for your referral?
Name of your general dentist*
Practice name/Location*
Phone number of your dentist (if known)
When was your last appointment or last check up? (if known)
FOR THE PARENT/GUARDIAN
Parent 1*
Mobile Number 1*
Parent 2
Mobile Number 2
Guardian
Guardian Mobile
PERSON RESPONSIBLE FINANCIALLY
Title*
First Name*
Last Name*
Date of Birth*

MonthDayYear
Address*
Mobile Number*
Private Health Fund (if applicable)
Email address (if different from above)
Signature*

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PATIENT - MEDICAL AND DENTAL HISTORY
Please indicate if you have confidential information that you want to discuss with the Orthodontist and not record on this form*

YesNo
Has your child commenced puberty?*

YesNo
Has the patient inherited any facial or dental characteristics? If yes, please detail*
Does the patient take any daily medication? (Including prescribed, over the counter or naturopathic/herbal)? If yes, please detail*
Any allergy to any medicines, chemicals or other substances (rubber, latex, antibiotics, peanuts etc)?*

YesNo
If yes to above, please detail
Please tick ONLY if the patient has, or has ever had, any of the following medical conditions

ArthritisADHDAdenoids removedAutism Spectrum DisorderAnaemia, Leukaemia or other blood disordersHeart Disease or complaintHeart murmur / Rheumatic FeverLiver problemsKidney problemsBleeding problemsMouth breathing due to nasal obstructionHigh or low blood pressureTonsils removedLung diseaseContact with AIDS (HIV) virusCerebral PalsyEpilepsySpeech & hearing problem
Any other conditions which may affect ability to undertake orthodontic treatment (please list)*
HAS THE PATIENT
Had any significant health problems in the past? If yes, please detail*
Any current health problems? If yes, please detail*
Any behavioural concerns that may preclude orthodontic treatment?*

YesNo
If yes to above, please detail
Had an orthodontic consultation previously?*

YesNo
Had any orthodontic treatment previously? If yes, please give details*
Had an injury to the primary or permanent teeth? If yes, please give details*
Had an injury to the face, jaws or chin? If yes, please give details*
HAS THE PATIENT EVER
Sucked his/her thumb or finger, or similar habit?*

YesNo
Experienced clicking, popping or grating sound from the jaw joint?*

YesNo
Experienced pain from the jaw joints or facial muscles?*

YesNo
Should be Empty: