Contact Details (enables provision of itemised statements for health fund purposes) First Name Surname Street Address Street Address line 2 City State NSWACTQLDVICSAWANTTAS Postcode blank Home Phone Mobile Phone Email Date of Birth Referral Details Who recommended you to this practice? Dentist’s Name Dentist’s Suburb Medical History Please indicate if any of the following apply Antibiotic prophylaxis prior to dental procedures Allergies Asthma Epilepsy Cleft Lip HIV+ Heart condition Diabetes Behavior/Medical Conditions (eg Anxiety, Autism, Sensory) Habitual Behaviour (eg Grinding, clenching, mouth breather) Blood Clotting Problems Bone disorders (eg Osteoporosis, Arthritis) Other Please specify other Are you taking any medication? Yes No What is the medication for? Dental History Has there ever been a hard knock to, or fracture of, teeth or jaws? Yes No Please give details of the injury that occurred Any jaw joint problems or clicks? Yes No Have any of the teeth had root canal therapy or very deep fillings? Yes No Orthodontics In your own words, describe the problem with the jaws or teeth as you see it: Have you consulted an orthodontist previously? Yes No Do you have any friends or family that are patients at MyOrthodontist? Yes No Please provide their name Submit Thank you for completing our patient form. The form has been sent. An error occured. Book your appointment with us today Don’t wait any longer to celebrate your new smile! Book Now
