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Two-Phase Treatment
Jaw Surgery
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Braces
Suresmile
Orthodontic Appliances
Resources
What is Orthodontics?
Common Orthodontic Problems
Your First Visit
Emergency Care
FAQ
Contact
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About Us
Our Team
Our Facilities
Our Technologies
Services
Children & Teens Treatment
Adult Treatment
Two-Phase Treatment
Jaw Surgery
Clear Aligners
Braces
Suresmile
Orthodontic Appliances
Resources
What is Orthodontics?
Common Orthodontic Problems
Your First Visit
Emergency Care
FAQ
Contact
Connect with us:
Doctor referral Form
(03) 95080555
team@alexyusupov.com.au
New Patient Form - Adult
New Patient Form - Adult
Personal details - New Patient Form - Adult
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 4
Title
Dr
Miss
Ms
Mr
Mrs
Name
*
First
Last
Preferred name
First
Last
Date of Birth
*
Home Address:
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Email
*
Work Phone Number
Home Phone Number
Mobile Phone Number
*
Occupation
*
Emergency Contact
Name
*
First
Last
Phone
*
Person Responsible for fees
Person Responsible for fees
*
Self
Other
Name
*
First
Last
Address
*
Address Line 1
City
State / Province / Region
Postal Code
Contact Number
*
Next
Do you have health insurance
Do you have health insurance
*
Yes - Dental
Yes - Dental & Hospital
No - Dental
No - Dental & Hospital
Medicare Details
Medicare number:
Individual Reference Number
Expiry Date
Medical History
Rheumatic Fever
Hepatitis
Lung disease
Asthma
Heart problems
Pacemaker
Digestive problems
Diabetes
HIV/Aids
Anxiety
Nasal problems
Sleep apnea
Back problems
Stroke
Infectious diseases
Osteoporosis
Neurological problems
Epilepsy
Any major surgery in last 5 years?
1
2
3
4
5
Other
Are you pregnant or hoping to be so?
Yes
No
If so, how many weeks?
1 week
2 weeks
3 weeks
4 weeks
5 weeks
6 weeks
7 weeks
8 weeks
9 weeks
10 weeks
11 weeks
12 weeks
More than 12 weeks
Do you smoke?
Yes
No
How many per day
0 - 5
6 - 10
10 -20
More than 20
Any other relevant medical history?
Allergies and adverse reactions
Do you have any allergies?
Yes
No
Sate Allergy and emergency plan
Medicines
Please indicate any medications that you are currently taking or have taken recently (including natural therapies).
Next
Orthodontic information
Have you had previously?
Orthodontic opinion:
Yes
No
Orthodontic treatment
Yes
No
In your own words, what concerns you about your teeth, OR What is the purpose of your visit?
Who is concerned about your teeth and/or jaws?
Self
Your partner/family
Your dentist
no one
Is this consultation related to Work related injury or Transport Accident?
Yes
No
When was the accident/injury?
Do you have a history of trauma to the teeth or jaws?
Yes
No
When was the accident/injury?
Is there anything you want to discuss with Dr Yusupov in private?
Yes
No
Next
General Dentist
Name of Dentist
Location
Date of last check up
Referrals, correspondence and appointments
Recommended by
Email Reports to you
Yes
No
Email reports to dentist
Yes
No
Email reports to specialists
Yes
No
Can we SMS appointment reminders to you?
Yes
No
Terms & Conditions
*
I agree to be responsible for all payment of fees and understand that payment is due at the time of the service
Submit
New Patient Form - Adult
Personal details - New Patient Form - Adult
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 4
Title
Dr
Miss
Ms
Mr
Mrs
Name
*
First
Last
Preferred name
First
Last
Date of Birth
*
Home Address:
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Email
*
Work Phone Number
Home Phone Number
Mobile Phone Number
*
Occupation
*
Emergency Contact
Name
*
First
Last
Phone
*
Person Responsible for fees
Person Responsible for fees
*
Self
Other
Name
*
First
Last
Address
*
Address Line 1
City
State / Province / Region
Postal Code
Contact Number
*
Next
Do you have health insurance
Do you have health insurance
*
Yes - Dental
Yes - Dental & Hospital
No - Dental
No - Dental & Hospital
Medicare Details
Medicare number:
Individual Reference Number
Expiry Date
Medical History
Rheumatic Fever
Hepatitis
Lung disease
Asthma
Heart problems
Pacemaker
Digestive problems
Diabetes
HIV/Aids
Anxiety
Nasal problems
Sleep apnea
Back problems
Stroke
Infectious diseases
Osteoporosis
Neurological problems
Epilepsy
Any major surgery in last 5 years?
1
2
3
4
5
Other
Are you pregnant or hoping to be so?
Yes
No
If so, how many weeks?
1 week
2 weeks
3 weeks
4 weeks
5 weeks
6 weeks
7 weeks
8 weeks
9 weeks
10 weeks
11 weeks
12 weeks
More than 12 weeks
Do you smoke?
Yes
No
How many per day
0 - 5
6 - 10
10 -20
More than 20
Any other relevant medical history?
Allergies and adverse reactions
Do you have any allergies?
Yes
No
Sate Allergy and emergency plan
Medicines
Please indicate any medications that you are currently taking or have taken recently (including natural therapies).
Next
Orthodontic information
Have you had previously?
Orthodontic opinion:
Yes
No
Orthodontic treatment
Yes
No
In your own words, what concerns you about your teeth, OR What is the purpose of your visit?
Who is concerned about your teeth and/or jaws?
Self
Your partner/family
Your dentist
no one
Is this consultation related to Work related injury or Transport Accident?
Yes
No
When was the accident/injury?
Do you have a history of trauma to the teeth or jaws?
Yes
No
When was the accident/injury?
Is there anything you want to discuss with Dr Yusupov in private?
Yes
No
Next
General Dentist
Name of Dentist
Location
Date of last check up
Referrals, correspondence and appointments
Recommended by
Email Reports to you
Yes
No
Email reports to dentist
Yes
No
Email reports to specialists
Yes
No
Can we SMS appointment reminders to you?
Yes
No
Terms & Conditions
*
I agree to be responsible for all payment of fees and understand that payment is due at the time of the service
Submit