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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
Menu
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 - Child
New Patient Form - Child
Personal details - New Patient Form - Child
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 4
Date of Birth
*
Name
*
First
Last
Preferred name
First
Last
Parent 1
Name
*
First
Last
Mobile Phone Number
*
Work Phone Number
Home Phone Number
Home Address:
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Email
*
Occupation
*
Parent 2
Name
First
Last
Mobile Phone Number
Work Phone Number
Home Phone Number
Home Address:
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Email
Occupation
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 Number:
Expiry Date:
Individual Reference Number
Have we treated any other family members
Yes
no
Third Choice
If yes, who?
Medical History
Rheumatic Fever
Hepatitis
Lung disease
Asthma
Heart problems
Digestive problems
Diabetes
Anxiety
ADHD
Speech or hearing problems
Epilepsy
Has your child any any major surgery?
Yes
no
Third Choice
Any other relevant medical history?
Allergies and adverse reactions
Does your child 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
Has your child had previously?
Orthodontic opinion:
Yes
No
Orthodontic treatment
Yes
No
In your own words, what concerns you about your child's teeth. What is the purpose of your visit.
Who is concerned about your child's teeth and/or jaws?
Self
Your partner/family
Your dentist
no one
Does your child have a history of trauma to the teeth or jaw?
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 - Child
Personal details - New Patient Form - Child
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 4
Date of Birth
*
Name
*
First
Last
Preferred name
First
Last
Parent 1
Name
*
First
Last
Mobile Phone Number
*
Work Phone Number
Home Phone Number
Home Address:
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Email
*
Occupation
*
Parent 2
Name
First
Last
Mobile Phone Number
Work Phone Number
Home Phone Number
Home Address:
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Email
Occupation
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 Number:
Expiry Date:
Individual Reference Number
Have we treated any other family members
Yes
no
Third Choice
If yes, who?
Medical History
Rheumatic Fever
Hepatitis
Lung disease
Asthma
Heart problems
Digestive problems
Diabetes
Anxiety
ADHD
Speech or hearing problems
Epilepsy
Has your child any any major surgery?
Yes
no
Third Choice
Any other relevant medical history?
Allergies and adverse reactions
Does your child 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
Has your child had previously?
Orthodontic opinion:
Yes
No
Orthodontic treatment
Yes
No
In your own words, what concerns you about your child's teeth. What is the purpose of your visit.
Who is concerned about your child's teeth and/or jaws?
Self
Your partner/family
Your dentist
no one
Does your child have a history of trauma to the teeth or jaw?
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