Find us at our convenient locations!
Aspley
0402 506 602
Bulimba
0402 506 602
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Orthodontic treatment
We provide a range of orthodontic options for children, teens and adults.
Book an appointment
History
Medical Form
Name
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Prefix
First
Last
DOB
(Required)
DD slash MM slash YYYY
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Mobile
(Required)
Email
School (if applicable)
Contact Phone Home
(Required)
Work
(Required)
Contact Phone Work
(Required)
For the Parent/ Guardian 1:
Name
First
Last
Mobile
(Required)
Email
(Required)
Contact Phone Home
(Required)
Contact Phone Work
(Required)
For the Parent/ Guardian 2:
Name
First
Last
Mobile
(Required)
Email
(Required)
Contact Phone Work
(Required)
Contact Phone Home
(Required)
Person responsible for payment of account
Name
First
Last
Billing Party Mobile
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Are you in a private health fund?
Yes
No
How did you find us?
Web
Google
Friend Referral
Family Referral
Dentist Referral
Name of Dentist & Practice
Medical History
Have you reached puberty? eg. Menstruation for girls; Voice change for boys
(Required)
Yes
No
Are you currently being treated by a medical practitioner?*
(Required)
Yes
No
Are you currently taking any tablets or medications?*
(Required)
Yes
No
Do you require antibiotic cover for dental treatment?*
(Required)
Yes
No
Are you allergic to any drugs or medicines?*
(Required)
Yes
No
Are you allergic to nickel or latex?*
(Required)
Yes
No
Have you ever been treated for osteoporosis?*
(Required)
Yes
No
Have you ever received bisphosphonate therapy?*
(Required)
Yes
No
Do you smoke?*
(Required)
Yes
No
Are you or might you be pregnant?*
(Required)
Yes
No
Please tick if you currently have or previously had any of the following
Asthma
Steroid therapy
Rheumatic Fever
Radiation therapy
Cancer (benign or malignant)
Hepatitis or other liver disease
Diabetes
Excessive bleeding
High blood pressure
Kidney disease
Epilepsy
Heart complaint
Nervous condition
Cardiac pacemaker
Tuberculosis
Stroke
Heart murmur
Stomach or digestive condition
Prosthetic implant
Contact with HIV
Anaemia, leukemia/other blood diseases
Lung disease
Transplanted organ or marrow
None of the above
Dental History
Dentist Name
(Required)
Practice Name
(Required)
Practice Suburb/Location
(Required)
Date of Last Check-Up
MM slash DD slash YYYY
Family Physician
Patient Referred By
Have you had problems with decay or gum disease?*
(Required)
Yes
No
Do you often suffer from dry mouth or oral ulceration?*
(Required)
Yes
No
Do you often suffer from jaw pain, clicking or locking?*
(Required)
Yes
No
Has the patient had any cysts or tumours of the jaws or gums?
(Required)
Yes
No
Had any injury to the teeth (this includes baby & permanent teeth)?
(Required)
Yes
No
Provide Details of Injury to Teeth
Smile Evaluation
Has the patient had an orthodontic consultation previously?
Yes
No
Has the patient had any previous orthodontic treatment?
Yes
No
My / My child’s concerns with my smile are: (please tick the relevant boxes below)
(Required)
Food traps between my teeth during eating
A narrow smile
Pain in my teeth, jaw, head or neck
Large black gaps at the corners of my mouth
Lisp when I speak
Symmetry of my teeth
Crooked or overlapping teeth
I grind my teeth
The way my teeth look in photographs
Gummy Smile
Suck fingers or thumb or have similar habit
The way my teeth look from the side
Spaces between my teeth/missing teeth
Other
If Other please provide further details
If you require treatment, which treatment method do you prefer?*
(Required)
Braces
Invisalign
Early Treatment
Nil, Dr Advice
Do you have any important life events (i.e. wedding) coming up that you would like to prepare your smile for*
(Required)
Yes
No
If so, please give details
Are there any other concerns you’d like to discuss with us today?*
(Required)
Yes
No
If Yes, please provide details.
We respect your privacy
Orthodontic records including x-rays, photographs, clinical details, medical and dental history, and personal information are necessary to provide you the best orthodontic care in our practice. Occasionally it may be necessary to provide your information to relevant third parties. Examples of this would be your health fund asking for the date treatment commenced, a friend or relative confirming appointments, etc.Your records may also be used for consultation with other medical and dental professionals in order to provide you with the best and most up to date treatment possible.If you wish to vary this consent we will require written advice from you.If you understand and accept the above, please sign below to show your consent. (If patient is under 18 a parent or guardian must sign and print their details on behalf of the patient)
Cancellation Policy
I understand that failures to appointments without at least 48 hours notice will incur a no-show fee of $70.
Name
(Required)
First
Last
Relationship To Patient
Date
MM slash DD slash YYYY
Signature
Δ
Book an appointment
Call us on
0402 506 602
or
Book online today
Aspley
Bulimba
