New Patient Questionnaire

Patient Details

Parent Details (if applicable)

Title *

First Name *

Last Name *

Date of Birth *

Mobile *

Home

Work

Email *

Address *

City *

State *

Postcode *

What School, University or Occupation

Year

Do any other family members attend this practice? *

Yes, please list names below

Who recommended our practice?

Dentist

Family/Friend

Other

Title

First Name

Last Name

Mobile

Home

Work

Title

First Name

Last Name

Mobile

Home

Work

Person Responsible for Accounts

Names *

Email *

Address *

City *

State *

Postcode *

Your Dentist

Name

Suburb

Consent to communicate with your dentist?

Yes

Dental History

Dental check-up frequency

Twice a year

Once a year

Emergencies

When was your last general dental check-up?

Any trauma to the face or teeth *

Yes

Any deep fillings or nerve damage *

Yes

Any periodontal or gum disease *

Yes

Any problems with your jaw joints *

Yes

If YES to any of the above please describe

Orthodontic History

What do you wish to accomplish with orthodontic treatment?

Patient's orthodontic treatment history

None

Previous treatment

Consultation only

Parents' orthodontic treatment history

None

Mother

Father

Medical History

Are you currently undergoing any medical treatment or care? *

Yes

Have you ever had, or do you currently have: *

Heart Murmur

Yes

Rheumatic Heart Disease

Yes

Bleeding Disorders

Yes

High or Low Blood Pressure

Yes

Asthma

Yes

Eczema

Yes

Diabetes

Yes

ADD or ADHD

Yes

Epilepsy

Yes

Tuberculosis

Yes

Hepatitis

Yes

HIV or AIDS

Yes

Any Other Medical Conditions

Allergies *

None

Latex

Nickel

Any Other Allergies

Any Medications, Supplements or Drugs being taken

What is Orthodontics?

Why see a Specialist?

Information Brochures


Braces		Lingual Orthodontics
Invisalign		Surgical Orthodontics
Expansion>		Functional Appliances

New Patient Questionnaire

Online Referral