Contact Details Patient's Name Preferred Name Street Address Street Address line 2 City State NSWACTQLDVICSAWANTTAS Postcode School Attended Home Phone Mobile Phone Email Date of Birth Referral Details Who recommended you to this practice? Dentist’s Name Dentist’s Suburb Responsible Party’s Details (enables us to provide itemised statements for health fund purposes) First Name Surname Street Address Street Address line 2 City State NSWACTQLDVICSAWANTTAS Postcode blank Medical History Please indicate if any of the following apply: Antibiotic prophylaxis required for dental procedures Allergies Asthma Epilepsy Cleft Lip HIV+ Heart condition Diabetes Bone disorders (eg Osteoporosis, Arthritis) Behavioural/Medical Conditions (Autism, Sensory, Anxiety) Habitual Behaviours (Thumb sucking, grinding/clenching, Mouth breathing) Ever received speech therapy Blood Clotting Problems Bone disorders (eg Osteoporosis, Arthritis) Other Please specify other Is the child taking any medication? Yes No What is the medication for? Maturation Child's gender: Female Male Has she reached menstruation/puberty? Yes No At what age? Has his voice changed? Yes No At what age? Has there been rapid growth recently? Yes No Sibling's maturation rate (brothers and sisters early or late growers): Early Average Late Height of father (in cm) Height of mother (in cm) 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 occured 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: Has the child previously had an orthodontic assessment Yes No Does patient have siblings/family members or friends that attend MyOrthodontist? Yes No Please provide 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
