» New Patient Form

Patient's Information
Salutation
Preferred name
Name (as listed on your current Medicare card)
First Middle Last
Age
Gender
Date of Birth

Day
Month
Year
Address
Suburb
State / Postcode
Home Phone
Work Phone
Mobile Phone
Email Address
Private Health Insurance Provider
Do you have a referral or other document you would like to provide us?
Max. file size: 2 MB.
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Is there anything else we should know? If so, please describe
Responsible Party's Information
The Responsible Party is the person assuming financial responsibility for the treatment.
Responsible Party's Name
First Last
Parent/Guardian's Name (if different person)
First Last
Salutation
Relationship to Patient
Billing Address
Suburb
State / Postcode
Home Phone
Mobile Phone
Responsible Party Work Name
Responsible Party Work Address
Responsible Party Work Phone
Responsible Party Email Address
Preferred Contact Option
- Home Phone
- Mobile Phone
- Work Phone
- Email
Please provide the following important information
Name of Patient's Dentist
Address of Dentist Practice
Dentist Practice Phone Number
Name of General Medical Practitioner
Address of GP Practice
GP Practice Phone Number
In case we cannot contact/reach you:
Person to Contact
Phone Number
Email
Any other information
Please answer the following questions
Please tick the main concern(s) you have with your teeth and or jaws.
- Crooked Teeth
- Crowding
- Spacing
- Overbite
- Underbite
- Protrusion
- Gum Problems
- Grinding
- Receding Jaw
- Prominent Jaw
- Jaw Pain / Clicking
- Other
Outline any problem more specifically if required
How frequently do you visit the dentist?
- Every 6 months
- Every 12 months
- Infrequently
Have you had any major dental work?
- Yes
- No
If yes, please outline details:
Have you had any previous orthodontic work?
- Yes
- No
If yes, please outline details:
Have you had any trauma (falls, knocks or bumps) to your teeth, or face?
- Yes
- No
If yes, please outline details:
Please provide an outline of family dental/orthodontic history.
This will assist in determining contribution of hereditary versus environmental factors in the cause of any orthodontic problem.
Siblings
Name Age Any problems with alignment of teeth Any orthodontic treatment
Mother
Any problems with alignment of teeth Any orthodontic treatment
Father
Any problems with alignment of teeth Any orthodontic treatment
Patient Medical History
Have you ever had any of the following? Please indicate:
- High blood pressure
- Heart ailment
- Rheumatic fever
- Asthma, chest or breathing problems
- Tuberculosis
- Stomach or bowel problems (e.g. ulcer)
- Kidney disease
- Diabetes
- Thyroid Problems
- Excessive bleeding or blood disorder
- Epilepsy
- Hepatitis
- AIDS/HIV
Provide details on these or any other previous illnesses
Have you ever been hospitalized? (Please provide details)
Have tonsils or adenoids been removed? If so, at what age?
Tonsils (Age)
Adenoids (Age)
Do you smoke?
- Yes
- No
How many a day?
Would you like to stop?
- Yes
- No
Female patients, are you pregnant?
- Yes
- No
Do you have: an artificial hip, heart valve or other prosthetic implant?
- Yes
- No
Have you had any problems with dental treatment?
- Yes
- No
Are you presently under medical care?
- Yes
- No
Would you like to discuss these questions in private with the orthodontist?
- Yes
- No
Are you taking any drugs, medicines or tablets? (Please list)
Do you have any allergies to any medicines or products? (Please list)
Medical Records
Do you have any medical conditions which may affect the taking of xrays? (Such as Parkinson’s disease, history of strokes, fainting spells, mental illness etc.).
- Yes
- No
Do you consent to us sharing your records and information with an external healthcare provider(for example general dentist, radiologist)
- Yes
- No
Do you agree to inform us if you are pregnant?
- Yes
- No
THANK YOU FOR YOUR ASSISTANCE IN COMPLETING THIS FORM AS FULLY AS POSSIBLE

By submitting, you agree that you have completed this questionnaire to the best of your knowledge and understand that failure to make a full disclosure may place you at undue medical risk. You understand that notes, radiographs (x-rays) or models relating to your treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this. You also give your permission for the practice to use the above contact details to send you appointment and checkup reminders.
Responsible Party Signature*
Reset
I am aware It is my responsibility to inform this office of any changes in the information provided in the form above.
File
Max. file size: 2 MB.

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After your form has been submitted a PDF of the content is generated and sent to our reception via our secure email platform. Immediately after the PDF is generated all parts of the form except the First, Middle and Last Name of the patient are encrypted in our database and erased after 72 hours.

Name	Age	Any problems with alignment of teeth	Any orthodontic treatment

Patient's Information

Responsible Party's Information

Please provide the following important information

In case we cannot contact/reach you:

Please answer the following questions

Please provide an outline of family dental/orthodontic history.

Patient Medical History

Have tonsils or adenoids been removed? If so, at what age?

Medical Records

THANK YOU FOR YOUR ASSISTANCE IN COMPLETING THIS FORM AS FULLY AS POSSIBLE

I am aware It is my responsibility to inform this office of any changes in the information provided in the form above.

About privacy and security:

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