Clone of New Patient Enrollment Form

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

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?

Medical History Form