NEW PATIENT INFORMATION

General Information

Please select our Practice Location you are attending *BooragoonBroomeSubiaco

 

MrMrsMsMissMx

Patient First Name *

Patient Surname *

Preferred Name

Gender *

FemaleMaleUnspecified

Date of Birth *

Email Address *

CalculatedAgeNow

Mobile Phone *

Residential Address *

Street *Street address line 2

Suburb *

State *Please selectWA

Postcode *

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Is your Postal Address different? *

YesNo

 

Postal address *Street address line 2

Suburb *

State *Please selectACTNSWNTQLDSATASVICWA

Postcode *

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Related patient(s) that are or have been under our care

How did you hear about us? *

WebsiteDentistYellow/White PagesReferred by current/past patientOther

 Please specify.

Parent Information

Parent (1) First Name *

Parent (1) Surname *

Is the address, email, mobile number different from the Patient Information entered above? *

YesNo

Address - Parent (1)

Street addressStreet address line 2

City

StatePlease selectACTNSWNTQLDSATASVICWA

Postcode

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Email Address (Parent 1)

Mobile Number (Parent 1)

Parent (2) First Name

Parent (2) Surname

Is the address different from the Patient information entered above?

YesNo

Address - Parent (2)

Street addressStreet address line 2

City

StatePlease selectACTNSWNTQLDSATASVICWA

Postcode

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Email Address (Parent 2)

Mobile Number (Parent 2)

Emergency Contact Information

Emergency Contact Full Name *

Phone Number *

Emergency contact’s relationship to you *

Treatment Information

Are you interested in *

InformationTreatment at this timeClarification of previously conflicted treatment

Is there any specific orthodontic treatment you are interested in? *

Conventional BracesCeramic BracesInvisalignLingual BracesOrthognathic Jaw SurgeryOther

 Please specify.

If your teeth were to be changed, how would you like them changed? *

Upper teeth - forward/backwardLower teeth - forward/backwardUpper teeth - gum shows too muchClose SpacesImprove the appearance of chipped/cracked/stained/pointed/dark teethStraighten crowded teethOther

Other:Please specify.

Is there anything about your child's medical, dental, social or emotional history that you feel the doctor should know? Include anything which could possibly affect your child's motivation and cooperation in wearing braces *

Person responsible for paying this account

Are you responsible for paying your own Orthodontic Account? *

YesNo

Please note: Notification of appointments will be sent via email and SMS to the Responsible Party only. Please complete the details of the person responsible for paying the account.

 

MrMrsMsMissCompany

Company Name

First Name *

Surname *

Relationship to patient *

Mailing Address - If different from Address supplied above

AddressAddress line 2

Suburb

StatePlease selectACTNSWNTQLDSATASVICWA

Postcode

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Email AddressIf different from the above.

Contact NumberIf different from the above.

Is Co-Parenting Involved *

YesNo

If co-parenting is involved, who is the Custodial Parent? *

Will the account for treatment need to be split between two parties? If yes please notify us once you have completed this form. *

YesNo

The parent/guardian who has signed as the responsible person is to pay for the services and seek reimbursement directly from the other parent/guardian. Assignments of responsibility for a child(s) account can be changed when a written request is received from both parties.

Do you have Orthodontic Private Health Insurance? *

YesNo

Name of Private Health Fund *

Do you have a Health Care Card / DVA / Other? *

YesNo

Name of Concession *

Medical History

General Practitioner Details

Name

Phone Number

Location

Are you allergic to any Antibiotics/Medications *

YesNo

Name of Antibiotic/Medication *

Type of Reaction *

Medical History Questionnaire

Medical Questions - Please select if any are applicable

Joint SwellingBone DisordersHeart ProblemsRheumatic FeverRheumatic Heart DiseaseAnaemiaHepatitisKidney DiseaseProlonged BleedingHigh Blood PressureDiabetesTuberculosisSpeech ProblemsEpilepsyThyroid ProblemsBrain InjuryArthritisEmotional ProblemsFaintness/DizzinessTonsils RemovedAdenoids RemovedTonsillitisNasal ObstructionEar achesRecurrent Sore ThroatsAllergiesDepressionAnxietyADHD

If you have selected any of the above Medical Questions, please provide details including medication *

Please list any past or present serious illnesses plus list medications currently being taken.

Is there any additional information that may relate to your current health status? *

YesNo

Please list information relating to your current health status

Dental History

Name of Referring Dentist

Name of General Dentist

Do you visit the Dentist regularly *

YesNo

Date of last dental visit

Has an Orthodontist been consulted previously? *

YesNo

Have dental x-rays been taken within the last six months? *

YesNo

Any injuries to face, mouth or teeth? *

YesNo

Thumb, finger or tongue habit? *

YesNo

Grinding of teeth? *

YesNo

More than average amount of decay? *

YesNo

Any extra permanent teeth? *

YesNo

Any teeth removed by extraction? *

YesNo

Difficulty in swallowing or chewing? *

YesNo

Pain or clicking on opening of mouth? *

YesNo

Sensitivity to hot, cold or sweets in any permanent teeth? *

YesNo

If you have answered YES to any of the above, please provide a more detailed description.

Adult Sleep Questionnaire

SNORING - Do you snore loudly? (louder than talking or loud enough to be heard through closed doors) *

YesNo

TIRED - Do you often feel tired, fatigued or sleepy during daytime? *

YesNo

OBSERVED APNEA - Has anyone observed you stop breathing during your sleep? *

YesNo

BLOOD PRESSURE - Do you have or are you treated for high blood pressure? *

YesNo

BMI - more than 35 kg/m2? (normal BMI is between 18.5 to 24.9) *

YesNo

AGE - Are you over 50 years old? *

YesNo

NECK CIRCUMFERENCE - Is your neck circumference greater than 40cm? *

YesNo

Sleep Questionnaire - 12 years and under

While Sleeping, does your child.....

Snore more than half the time? *

YesNo

Always Snore? *

YesNo

Snore loudly? *

YesNo

Have "Heavy" or loud breathing? *

YesNo

Have trouble breathing or struggle to breathe? *

YesNo

Have you ever.....

Seen your child stop breathing during the night? *

YesNo

Does your child.....

Tend to breathe through the mouth during the day?

YesNo

Have a dry mouth on waking up in the morning? *

YesNo

Occasionally wet the bed? *

YesNo

Wake up feeling unrefreshed in the morning? *

YesNo

Have a problem with sleepiness during the day? *

YesNo

Has a Teacher or other Supervisor commented that your child appears sleepy during the day? *

YesNo

Is it hard to wake your child up in the morning? *

YesNo

Wake up with headaches in the morning? *

YesNo

Did your child stop growing at a normal rate at any time since birth? *

YesNo

Is your child overweight? *

YesNo

This child often.....

Does not seem to listen when spoken to directly? *

YesNo

Has difficulty organising tasks and activities? *

YesNo

Is easily distracted by extraneous stimuli? *

YesNo

Fidgets with hands or feet or squirms in seats? *

YesNo

Is on the 'go' or often acts as if 'driven' by a 'motor'? *

YesNo

Has your child.....

A history of prematurity requiring ventilation? *

YesNo

Severe sleep apnoea diagnosed by a Doctor?

YesNo

A bleeding disorder? *

YesNo

Asthma? *

YesNo

Poor growth? *

YesNo

Confirmation

I confirm that above information I have provided is true, complete and accurate. *

Parent/Guardian name completing this form *

Signature *

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Date *

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