Scott Smith Orthodontics

We are open! The health and wellbeing of our patients and staff are always our first priority and we will continue to implement the recommended safety precautions.
Please click here for more information.
We are also still offering remote consultations, click here.

Fields marked * are required.

Personal details

Patient’s name* Address Postcode Gender Male Female Pregnancy Yes No Not Applicable Date of birth

Date of birth

Email* Phone* Payee’s name (person responsible for payment of account)* Payee’s number* Payee’s address* Private health fund* Dentist’s name*

Medical history

Patient's Medicare Number Patient's Medicare ID Number Does the patient have a health problem? If yes, please list Is there a history of serious illness, accident or operation? If yes, please list Is the patient under a doctor’s care for any problem at this time? If yes, please list Is the patient taking any medication? If yes, please list Does the patient have any allergies or drug sensitivities? If yes, please list

Dental history

Has the patient had an orthodontic consultation previously? Yes No Has the patient had any previous orthodontic treatment? Yes No Has the patient had any injury to the teeth? Y / N (this includes both baby & permanent teeth) Yes No Has the patient had any injury to the face, jaw or gums? Yes No Has the patient had any cysts or tumours of the jaws or gums? Yes No Have you been informed of any missing or extra permanent teeth? Yes No Does the patient suck fingers or thumb, or have a similar habit? Yes No Date of last dental examination Reason for seeking orthodontic treatment

Medical checklist

How did you find out about us?* Date:

Date

By clicking submit you are agreeing to our privacy policy

Fix my smile

Find out what orthodontic treatment you need. Go online and complete our 'fix my smile' questionnaire.

Fix my smile

Cost and Finance

0 ^%

interest payment plans

Treatment cost

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

Patient medical forms

Personal details

Medical history

Dental history

Medical checklist

Fix my smile

interest payment plans

Launceston

Ulverstone