New Patient Information

Please complete this form before your first visit. It takes about 5 minutes. Fields marked * are required. If the patient is under 18, a parent or guardian should fill it in.

Patient details
Health fund (Private Health Insurance)
Parent / guardian

Required if the patient is under 18. Add more parents / guardians with the button below.

About the patient
Has anyone in the family had orthodontic treatment?
Medical history
Are you taking any regular medications?
Do you have any significant medical conditions? (e.g. heart conditions, bleeding disorders, organ disease, asthma, diabetes)
Do you have any allergies?
Any operations or hospital stays?
Are you pregnant?
Dental history
Do you have a regular dentist?
X-rays
Have you had x-rays of your teeth or jaws taken before?
Your treatment
What are your main concerns about your teeth? (tick any)
What would you like to achieve with orthodontic treatment? (tick any)
Preferred payment option
How did you hear about us?
Confirm and sign

Attractive Orthodontics collects this information to provide orthodontic care, contact you and manage your account. It is sent securely to our practice only and handled under the Privacy Act 1988 and our privacy policy. You can ask to see or correct it at any time.

Signature
Sign here with your finger or mouse
Check your email address (so your copy can't go to the wrong person)

We'll email a 6-digit code to the address above. Or untick the box and download your copy after sending.

Date:

Your form is sent directly to our practice. Nothing is stored on this website.