PATIENT HISTORY – CONFIDENTIALPatient Information* Miss Mrs Ms Mr Mst Dr Name* Surname First Name Address* Address Suburb Postcode TelephoneHomeMobile*WorkEmail Address* Are you happy to receive correspondence (Patient correspondence only, no advertising) via email* Yes No Sex* Male Female Non Binary Other Date Of Birth*Parent/Guardian Details(If Applicable)Correspondence can be shared to (information regarding treatment and accounts, no advertising!):* Self Parent/Guardian 1 Parent/Guardian 2 Both Parent/Guardian 1TitleSurnameFirst NameAddress As above Other address parent 1SuburbPost CodeHome Phone (As above/other)MobileEmail Parent/Guardian 2TitleSurnameFirst NameAddress As above Other address parent 1SuburbPost CodeHome Phone (As above/other)MobileEmail Personal responsible for fees* Self Parent/Guardian 1 Parent/Guardian 2 Both Any Siblings: Name(s) and Age(s):Do you have Private Health Insurance for Dental?* Yes No If yes, which health fund?*Do you have Private Hospital insurance?* Yes No If yes, which health fund?*How did you find us? Facebook Website Google Drive/Walk By Dentist How did you find us? - Friend Friend Friend or Family Member NameHow did you find us?-Other Other OtherAccount Holder Self(as above) Parent/Guardian 1 Parent/Guardian 2 Other(relationship to patient) Account Holder Title Miss Mrs Ms Mr Mst Dr Name Surname First Name Address Address Suburb Postcode Telephone HomeMobileWorkDentist Information Surname First Name Last Dental VisitDoctor Information Surname First Name Dental HistoryWhat concerns you most about your teeth?Have any teeth been extracted?If so why?Injury involving the teeth, mouth or face?Past or present habits (i.e. Thumb/finger sucking, tongue thrusting, lip biting)?Past Orthodontic treatment (eg plates or braces)?Do you suffer pain in the jaw joints?Medical History Asthma Arthritis Hayfever Blood pressure Grommets Adenoids/ Tonsils Epilepsy Heart Problems Headaches/Migraines Diabetes Hepatitis Excessive Bleeding Rheumatic Fever Pregnant Osteoporosis Presently taking any medication? Y / N If yes please specify.AllergiesOther serious illness?Do you smoke? Y / N If yes how many a day?Developmental delays?Would you like to discuss any of these questions in private with the Orthodontist? Yes No CLINICAL PHOTOGRAPHY FORM PATIENT CONSENT At your initial consultation /examination, we will take a series of clinical photographs to assist in diagnosis and treatment planning. We are required to provide you with information about the reasons for, and the uses of, the proposed clinical photography. It is your responsibility to raise concerns with or seek further information from your health professional prior to agreeing to the use of clinical photos. Name* I, (given names) Surname Hereby consent to clinical photos and or images to be made of me/my child. I agree that the images may be used for: (please tick as appropriate) Patient Record The images will form part of the information collected for you or your child’s care and treatment. This information is handled in accordance with the Health Records Act 2001. Education and Training The images may be used for teaching purposes and viewed by other patients within the surgery or health professionals outside this surgery. The images may be used, for example, in talks, conference presentations, or patient display in surgery. Research This may involve the images being used, for example, in medical publications, journals, and textbooks. Health professionals, scientists, and medical researchers who use these publications in their professional education will see the images. The general public is unlikely to see the images. Images will not contain or be accompanied by"identifying information, such as name, however full confidentiality is not guaranteed. Signature of Guardian/PatientDateUpload Referral Form or X-raysMax. file size: 128 MB.NameThis field is for validation purposes and should be left unchanged.
