Wilkinson Orthodontics - Medical History Form

Patient Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: 0000-000-000.

Address

Street Address

Street Address Line 2

CityState / Province

Postcode

Gender

Dentist name

School name

Do you have a Medicare card?

Medicare Number

Pleas enter a 10-digit number

Medicare IRN

The number that appears before your name

Medicare Expiry

MM/YYYYFormat: 00/0000.

Parent or Guardian Name 1

Parent or Guardian Phone 1

Please enter a valid phone number.Format: 0000-000-000.

Parent or Guardian Name 2

Parent or Guardian Phone 2

Please enter a valid phone number.Format: 0000-000-000.

Use same details as above in 'Patient Information'

Billing name

Date of birth

Date

Billing email

Billing phone

Please enter a valid phone number.Format: 0000-000-000.

Billing Address

Street Address

Street Address Line 2

CityState / Province

Postcode

Relation to patient

Do you have Private Health Insurance?

If yes, which fund?

Please contact your private health insurance to check your orthodontic coverage

Do you require split billing for this patient?

Reason for seeking treatment

Have you received orthodontic treatment before?

If yes, please provide details

If yes, describe

When was the last time you visited a dentist?

Are you receiving any treatment with another medical or dental specialist?

If yes, what treatment and who is providing it?

Do you suffer from gastric reflux?

If yes, describe?

Do you grind your teeth or suffer from headaches?

Do you suffer from snoring or sleep apnoea?

Does the patient suck finger or thumb, or have a similar habit?

Are you taking any medication that thins your blood i.e anti-clotting medication?

Are you taking osteoporosis medication?

Have you ever had cancer or are you currently receiving treatment for cancer?

If yes, please provide cancer related details

Have you ever received Radiation Therapy to the head or neck region

If yes, please provide details (date and what for)

Are you currently receiving medical care or taking any other medications

If yes, please provide details

Have you had any of the following?

Other medical problems

Are you allergic to any drugs, medicines, or latex?

If yes, detail allergies

Do you have any other known allergies?

Is there a possibility that you could be pregnant?

If yes, what was this for and when was the admission

(Please tick as many as appropriate)

Can we ask who the friend or family was, so we can reach out to thank them

Do you consent to your consultation being recorded?

At Wilkinson 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:

Wilkinson Orthodontics collecting my personal information (including sensitive and health information) through the recording of my consultation for the purpose of maintaining precise clinical records;

Wilkinson Orthodontics using and disclosing my personal information (including sensitive and health information) for the purpose of maintaining accurate documentation of treatment discussions; and

Wilkinson 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 Wilkinson 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

Medical History Form

Parent/Guardian Information

Billing Party Information

Dental History

Medical History

How did you find out about us?

Patient Consent