Fields marked * are required.

Patient Details:

First Name *

Last Name*

Date of Birth*

Address*

Gender*

Male

Female

Non Binary

Please complete if Patient is under 18 years old

School

Grade

Mother’s Name

Mother’s Telephone

Father's Name

Father's Telephone

Sibling(s) Name & Age

Billing Details:

Name of the person responsible for the Account: (one name only)*

Address *

Home Phone

Work Phone

Mobile *

Email *

Dental History:

General Dentist *

Date of last Check and Clean *

Private Health Insurance Provider *

Has the patient inherited any family dental characteristics? *

Any major falls, accidents or operations involving the mouth area? *

What is your main concern in seeking this consultation? *

Has/Does the patient suck their thumb or fingers?*

Yes

Does the patient clench / grind their teeth at night?*

Yes

Does the patient have any difficulty breathing through the nose?*

Yes

Has the patient had any previous orthodontic treatment?*

Yes

Medical History

We Respect Your Privacy

In order to provide you with the highest standard of dental care, this is required to collect personal information from you. This information covers basic details such as your name, address and telephone numbers but it is also necessary for the dentist to obtain from you details regarding your general health and past medical or surgical events. Without this general health picture, the treating dentist is unable to plan your care properly.

Naturally, some of this information is of a personal nature and some of it might be regarded as ‘sensitive’ and not the sort of information that you would wish to be unnecessarily disclosed to others.

We value the need to safeguard this information and, in accordance with the principles laid down in privacy legislation and the guidelines issued by the Australian Dental Association, we would like to assure you that:

This information will only be used by the treating dentist in order to deliver your care to the highest standards.
It will not be disclosed to those not associated with your treatment, without your express consent.
You may seek access to the information held about you and we will provide this access without delay. This access might be by inspection of your dental records at the time of appointment or by special access or copying of information at other times.
There will be no charge made for requesting this information but there may be fees levied just to cover the costs associated with the processing of this request of the copying of information.
We will take reasonable steps to ensure at all times that the details we keep about you are accurate, complete and up-to-date.
We will take reasonable steps to protect this information from misuse or loss and from unauthorized access, modification or disclosure.
Our staff are trained to respect these principles at all times.

If you have any questions regarding the information we collect from you and hold in your dental records, please do not hesitate to ask us. We are acting in your interests at all times.

Date*

Relationship to patient *

Signature of person completing this form:

By submitting this form, you are agreeing to our privacy policy.

Medical history form

Patient Details:

Please complete if Patient is under 18 years old

Billing Details:

Dental History:

Medical History

We Respect Your Privacy

Find us on the Gold Coast

Wilkinson Orthodontics Helensvale

Wilkinson Orthodontics Benowa