New Patient Form - Child

Patient

Date of Birth * First Name * Last Name * Preferred First Name * Preferred Last Name *

Parent/Guardian 1

First Name * Last Name * Email * Mobile Phone * Work Phone Number Home Phone Number Address * City * State * Postcode * Occupation *

Parent/Guardian 2

First Name Last Name Mobile Phone Number Work Phone Number Home Phone Number Address City State Postcode Email Occupation

Person Responsible for fees

Person * -- Please Select -- Parent/Guardian 1 (skip to next section) Parent/Guardian 2 (skip to next section) Other (enter details) First Name Last Name Address City State Postcode Phone Number

Do you have health insurance?

Health Insurance * -- Please Select -- Yes - Dental Yes - Dental and Hospital No Medicare Number Individual Reference Number Expiry Date

Have we treated any other family members? -- Please Select -- Yes No If yes, who?

Medical History

Plese select

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 other relevant medical history?

Allergies and adverse reactions

Does your child have any allergies? -- Please Select -- Yes No If yes, please state details

Medicines

Please indicate which medicine your child is currently taking or has taken recently (including natural therapies).

Orthodontic information

Has your child had previously?

Orthodontic Opinion -- Please Select -- Yes No Orthodontic Treatment -- Please Select -- Yes No Treatment Details Who is concerned about your child's teeth and/or jaws? -- Please Select -- Self Your Partner / Family Your Dentist No one Does your child have a history of trauma to the teeth or jaw? -- Please Select -- Yes No When was the accident/injury? Anything you want to discuss in private> -- Please Select -- Yes No

General Dentist

Name of Dentist Location Date of last dental check up

Referrals, correspondence and appointments

Recommended by Email Reports to you -- Please Select -- Yes No Email reports to dentist -- Please Select -- Yes No Email reports to specialists -- Please Select -- Yes No Can we SMS appointment reminders to you? -- Please Select -- Yes No

I agree to be responsible for all payment of fees and understand that payment is due at the time of the service * YES