Patient medical forms

Patient medical forms

Before you start treatment with our team here at Scott Smith Orthodontics, we need to know a little bit about you. Please fill in the form below prior to your first appointment. You can either fill in the form here or fill them in at reception when you arrive.

Fields marked * are required.

Personal details

Male Female Yes No Not Applicable

Medical history

Dental history

Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Medical checklist

Arthritis

Asthma

Epilepsy or convulsions

Hearing problems

Fainting or dizziness

Emotional problems

Bleeding disorders

Diabetes

Bone disorders

Syndromes

Heart diseases or murmur

Tonsilitis

HIV or AIDS

Tuberculosis

High risk group for AIDS

Cancer or tumour

Cleft palate

Endocrine problems

Joint problems or pain

Kidney problems

Learning disabilities

Rheumatic fever

Speech problems

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Before and afters

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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 Launceston

15 The Quadrant,
Ulverstone,
TAS 7315

Phone number

(03) 6331 7117