New Patient Form

Title* Mr Mrs Miss Ms Dr Other

Gender* Male Female Non Binary

First Name*

Last Name*

Address*

Postcode*

Date of Birth*

Phone*

Phone (Work)

E-mail*

Name of Parents*

Occupation Parent/Guardian*

Name of School Patient attends

Emergency Contact*

Relationship*

Person responsible for payment of accounts*

Private Health Fund (if applicable)

Name of Dentist/Practice details*

Date of last visit to the dentist and reason*

Name of any family members who attend Evolution Orthodontics

The state of your health may have a significant effect on your orthodontic care.

I have private and confidential medical matters which I wish to discuss with the orthodontist Yes No

Are you receiving any medical treatment at present? Yes No

Name of your medical practitioner/specialist*

Have you ever been in hospital?* Yes No

If yes, nature of hospitalisation and dates:

Please list any medications you are currently taking, or have been taking recently including injections, herbal remedies, vitamins, supplements, cold/flu treatments, sleeping pills, pain relievers, implants, so we can take appropriate precautions and avoid drug interactions.

Please list any known ALLERGIES or ADVERSE REACTIONS to drugs (especially antibiotics eg. penicillin), medicines, antiseptics, local anaesthetics, latex, preservatives that we should know about.

Please tick if you have ever had any of the following:

Do you suffer from any illness not listed above or carry any infectious disease? Yes No

If yes, please provide details

How did you hear about us?*

Is this a second orthodontic opinion?* Yes No

Do you have a referral from your dentist?* Yes No

Have any of these x-rays been taken in the last 3 months?*

OPG* Yes No

Lateral Cephalogram* Yes No

Any past orthodontic treatment? Please provide details*

Have you seen a Periodontist (gum specialist)?* Yes No

If yes, please provide details

Any past injury/surgery to the face/teeth/jaws? Please provide details*

Have you ever experienced any jaw joint (TMJ) symptoms such as clicking or poping noises, locking, pain, or limited mouth opening?* Yes No

Please detail your orthodontic concerns*

Are there any other conditions that you would like to disclose?*

Person who filled the form (if patient is under 18 years of age)* Myself Other

If other please provide details

In signing this form I acknowledge that this represents an accurate medical history. I will advise my orthodontist of any changes to my medical history in the future.
I understand that all medical details will be treated with complete professional confidentiality.
I have read the privacy document provided by this practice.

Date*

Blacktown

Dubbo

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The state of your health may have a significant effect on your orthodontic care.

Please tick if you have ever had any of the following:

Orthodontic concerns

DECLARATION

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