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Adult form

Patient Details

Patient's Name*

Surname Name*

Date of Birth*

Gender*

Male Female

Phone (h)

Phone (w)

Phone (m)*

Postal Address

Occupation

Dentist

Who referred you to our practice?

Private Health Fund*

Extras

Medical Doctor (GP)

GP Clinic

Person/s responsible for account

I agree to be financially responsible for the payment of account/s

Signed

Date

Or, please provide details if responsible party is different to patient

Mr / Mrs / Ms / Miss / Dr / Other*

Name*

Phone (h)

Phone (w)

Phone (m)*

Postal Address

Relationship to patient

Signed

Date

Patient's Name*

Date of Birth

Medical History

Have you been seriously ill or hospitalised before?*

Yes No

Please provide details

Are you currently taking any medication?*

Yes No

Please provide details

Do you have any allergies?*

Yes No

Please provide details

Have you been diagnosed with a medical condition?*

Yes No

Please provide details

History of any orthodontic problems in the family?

Yes No

Please provide details

Reasons for seeking orthodontic treatment

Appearance/alignment of teeth

Bite problem

Under instruction of referring orthodontist/dentist/therapist

Dr.

Dental History

Have you had a dental check up in the last 6 months*

Yes No

Have you experienced any of the following*

Significant Dental Treatment

Cavities

Teeth sensitivity

Bleeding gums after brushing

Clicking or locking of the jaw joint(s)

Injury to teeth

Injury to jaw/face

Please provide details

I CONFIRM THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE

Please sign here

I have read and accept the privacy policy of this form.

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Launceston
Ulverstone

Launceston

Ortho practice in Launceston

19 Brisbane Street,
Launceston,
TAS 7250

Phone number

(03) 6331 7117

Ulverstone

Ortho practice in Ulverstone

15 The Quadrant,
Ulverstone,
TAS 7315

Phone number

(03) 6331 7117