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Child form

Patient Details*

Miss / Master / Other*

Date of birth

Gender*

Male Female

Patient first name/s*

Patient Surname*

School attending

Sport/s

Dentist*

Dental Therapist

Medical Doctor/Clinic (GP)

Private Health Fund/Insurance*

Who referred you to us?

How did you hear about us?

Do you have relatives that attend our practice?

Please kindly inform us if you are have a cold, flu or other contagious illness before your visit, so that we can rearrange appointment times.

First Parent / Guardian Details

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

Name*

Contact telephone numbers*

Email address*

Postal address

Relationship to patient

Occupation

I agree to be financially responsible for the payment of account/s* full account 50% shared account

Signed

Date

Second Parent / Guardian Details

Mr / Mrs / Ms / Miss / Dr / Other

Name

Contact telephone numbers

Email address

Please tick if address details are the same for both parents.

Postal address

Relationship to patient

Occupation

I agree to be financially responsible for the payment of account/s full account 50% shared account

Signed

Date

Patient's Name*

Date of Birth

Medical History

Has the patient been seriously ill or hospitalised before?*

Yes No

Please provide details

Is the patient currently taking any medication?*

Yes No

Please provide details

Does the patient have any allergies?*

Yes No

Please provide details

Has the patient been diagnosed with a medical condition?*

Yes No

Please provide details

Growth History

Has the patient had a recent growth spurt?*

Yes No

Child/Adolescent Female Patients
Has menstruation begun? (this is important for assessing growth phase characteristics) If yes when*

Yes No

Family History

Mother’s height (cm)

Father’s height (cm)

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

Has the patient had a dental check up in the last 6 months*

Yes No

Has the patient 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

Relationship to patient*

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.

Please sign here:

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