Find us at our convenient locations!
Aspley
0402 506 602
Bulimba
0402 506 602
Welcome
Meet Us
Patient Information
Medical History
FAQs
Why choose Orthosmile
Fees and payments
Care of braces
Treatments
Children’s orthodontics
Preventive care and appliances
Teenager orthodontics
Adult orthodontics
Orthognathic surgery
Braces and appliances
Lingual Braces
Invisalign
Emergencies
Smile Gallery
Videos
Blog Corner
Tour Practice
Contact Us
Orthodontic treatment
We provide a range of orthodontic options for children, teens and adults.
Book an appointment
Medical History
Medical Form
Name
First
Last
DOB
(Required)
DD slash MM slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Mobile
(Required)
Work
Email
(Required)
Billing Party Details
First
Last
Billing Party Mobile
(Required)
Billing Party DOB
(Required)
DD slash MM slash YYYY
How did you find us?
Web
Google
Friend Referral
Family Referral
Dentist Referral
Name of Dentist & Practice
Medical History
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
Rheumatic Fever
Radiation therapy
Hepatitis
Diabetes
Excessive bleeding
High blood pressure
Kidney disease
Epilepsy
Heart complaint
Cardiac pacemaker
Tuberculosis
Stroke
Prosthetic implant
Contact with HIV
Lung disease
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
Have you had trauma to any teeth? At what age did this occur?*
(Required)
Yes
No
Have you had problems with decay or gum disease?*
(Required)
Yes
No
Do you often suffer from jaw pain, clicking or locking?*
(Required)
Yes
No
Do you often suffer from dry mouth or oral ulceration?*
(Required)
Yes
No
Smile Evaluation
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
The way my teeth look from the side
Spaces between my teeth/missing teeth
Other
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
Are there any other concerns you’d like to discuss with us today?*
(Required)
Yes
No
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
Consent
I agree to the privacy policy.
Δ
Treatments
Children’s orthodontics
Teenager orthodontics
Adult orthodontics
Braces and appliances
Invisalign
Emergencies
Book an appointment
Call us on
0402 506 602
or
Book online today
Aspley
Bulimba