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New Patient Questionnaires

For Children

New Patient Questionnaire (Child)

Patient Details-

Full Name: Birthdate: (dd-mm-yyyy) some browsers use dd-Jan-yyyy format
Address: Postcode:
Phone: (Home) Phone: (Mobile)
Email:
School/College:
Name of Referrer:
Who recommended you to this practice?
Usual Dentist: (Name and Suburb)
Other members of family who have attended this orthodontic practice:




Parent's Details-

Mum's Full Name: Phone:
Dad's Full Name: Phone:

Billing Details (who is responsible for accounts) -

Full Name:DrMrMrsMsMiss Phone:
Address:




Medical History

List any serious illnesses or allergies e.g Heart conditions, bleeding disorders, diabetes, epilepsy, asthma, etc:



Are you taking any medications?



Are you at present receiving medical attention?



Have you had, or has it ever been recommended you have your tonsils and/or adenoids removed?




Dental & Orthodontic History

Have you had any serious injuries to your teeth or jaws?



Have you had any jaw pain, problems or clicks?



Have you had any teeth with deep fillings, root canal therapy or any teeth that your dentist is particularly concerned about?



Are you a mouth breather?



Do you or did you ever such your thumb or fingers after the age of 6?



Have you had, or has it been recommended that you have speech therapy?



Have you had, any previous orthodontic treatment or consultation?



What is your reason for seeking orthodontic treatment?





Please indicate the patient's concern for correction of orthodontic concerns?

Very concernedConcernedIndifferentOpposed

Please indicate the parent's concern for correction of orthodontic concerns?

Very concernedConcernedIndifferentOpposed

Patient Consent

Parent/Guardian, please check the box if you consent to the following, on behalf of your child/dependent:

- I agree that if I do not attend my orthodontic appointment or fail to give 24hr notice to cancel my appointment, I will be required to pay a $20 Non-Attendance Fee. I am also aware that if I run more than 15mins late to my appointment, that I will need to reschedule for another appointment.

- I agree to allow my orthodontist to communicate relevant orthodontic information to orthodontists, orthodontic staff, dentists and other relevant specialists involved in my orthodontic care. I also understand that should I not want my orthodontic or personal information disclosed to other orthodontists or staff of this practice, I need to inform my orthodontist.

Consent

For Adults

New Patient Questionnaire (Adult)

Patient Details-

Full Name: Birthdate: (dd/mm/yyyy) some browsers use dd/Jan/yyyy format
Address: Postcode:
Phone: (Home) Phone: (Mobile)
Email:
Occupation:
Name of Referrer:
Who recommended you to this practice?
Usual Dentist: (Name and Suburb)
Other members of family who have attended this orthodontic practice:




Billing Details (who is responsible for accounts) -

Full Name:DrMrMrsMsMiss Phone:
Address:




Medical History

List any serious illnesses or allergies e.g Heart conditions, bleeding disorders, diabetes, epilepsy, asthma, etc:



Are you taking any medications?



Are you at present receiving medical attention?



Are you pregnant or possibly pregnant?




Dental & Orthodontic History

Have you had any serious injuries to your teeth or jaws?



Have you had any jaw pain, problems or clicks?



Have you had any teeth with deep fillings, root canal therapy or any teeth that your dentist is particularly concerned about?



Are you a mouth breather?



Have you had, any previous orthodontic treatment or consultation?



What is your reason for seeking orthodontic treatment?





Please indicate your concern for correction of orthodontic problems?

Very concernedConcernedIndifferentOpposed

Patient consent

Please check the box if you consent to the following:

- I agree that if I do not attend my orthodontic appointment or fail to give 24hr notice to cancel my appointment, I will be required to pay a $20 Non-Attendance Fee. I am also aware that if I run more than 15mins late to my appointment, that I will need to reschedule for another appointment.

- I agree to allow my orthodontist to communicate relevant orthodontic information to orthodontists, orthodontic staff, dentists and other relevant specialists involved in my orthodontic care. I also understand that should I not want my orthodontic or personal information disclosed to other orthodontists or staff of this practice, I need to inform my orthodontist.

Consent