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

Date

Gender

School (if applicable)

E-mail

example@example.com

RESPONSIBLE PARTY

Name of person completing this form

Relationship to patient

Signature

Date

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

Address

Mobile Number

Private Health Fund (if applicable)

Email address (if different from above)

Signature

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

Has your child commenced puberty?

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)?

If yes to above, please detail

Please tick ONLY if the patient has, or has ever had, any of the following medical conditions

If yes to above, please detail

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?

If yes to above, please detail

Had an orthodontic consultation previously?

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?

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

Experienced pain from the jaw joints or facial muscles?

Scope Orthodontics may take clinical photographs, dental impressions, digital scans and x-rays of your face and teeth as part of your first consultation for the orthodontist. These records allow for a thorough assessment and formulation of a treatment plan specific to your needs.

Digital records will be kept within the practice management software on Australian servers in compliance with Australian data security requirements. Physical records will be stored according to national guidelines. These records may be sent to third-party companies for treatment planning and fabrication of appliances.

These records will form part of your dental health record and may be kept for a minimum of 7 years or up until the age of 25 for minors and are available to the patient/guardian upon request at any time.

You have the right to withdraw your consent at anytime but please be aware some clinical records are necessary to safely assess, plan, and provide orthodontic treatment.

Please speak to our friendly team if you have any questions or concerns.

I have read and understood this consent form. I have had the opportunity to ask questions, and I voluntarily consent to record taking as indicated above.

I consent to my photographs, radiographs and/or digital scans to be used for education, research and/or marketing purposes

Do you consent to your consultation being recorded?

At Scope Orthodontics, we record select consultations using secure and compliant professional software to ensure accurate documentation of treatment discussions, recommendations, and your questions. These recordings help us maintain precise clinical records to provide our team with an accurate reference of what was discussed during your consultation, and allow us to continuously improve the quality of care we deliver.

By checking the ‘Yes – I consent’, I acknowledge and consent on my behalf, or on behalf of the person who has authorised me to provide consent, to the following:

Scope Orthodontics collecting my personal information (including sensitive and health information) through the recording of my consultation for the purpose of maintaining precise clinical records;
Scope Orthodontics using and disclosing my personal information (including sensitive and health information) for the purpose of maintaining accurate documentation of treatment discussions; and
Scope Orthodontics disclosing my personal information (including sensitive and health information) to third parties, such as Gong.io Inc, so that these third parties can securely store consultation recordings on Scope Orthodontics ' behalf.

Recording will involve the collection of your personal and health information through sound recording.

All recordings will be securely stored by our service provider, Gong.io Inc, on cloud servers in the United States. Our service providers will only access the recordings to provide technical support and system maintenance. More information about Gong.io Inc's privacy practices is available at: FAQs: Security, Privacy and Compliance

To learn more about how we handle your personal information, how to request access to, or correction of, your personal information, how to make a privacy complaint and how we will deal it, please view our Privacy Policy at Gong Privacy Policy or contact the team at Reception.

You are not required to agree to the recording of your consultations, and if you do not agree, it will have no impact on the provision of our services to you.

Signature

Name

First NameLast Name

Date

PATIENT CONSENT