New Patient Questionnaire - Hunter Valley Orthodontics

PLEASE ONLY COMPLETE THIS FORM IF YOU HAVE A CONSULTATION BOOKED.

If you do not have a consultation booked, please call us on 1800 021 064 to schedule an appointment.

PERSONAL DETAILS

Select *

Patient Surname *

Patient Given Names *

Patient Preferred Name

Patient Date of Birth *

Gender *FMX

Patient Address *

Suburb *

State *

Post Code *

Home Phone

Work Phone

Email Address *

Mobile Phone

School Year

School Name

Work Name

Occupation

Competitive Sport Played

Musical Instruments Played

Medicare Card *

Patient's Position # *

Expiry Date *

Dentist's Name *

Dentist's Suburb *

Doctor's Name *

Doctor's Suburb *

What are your main concerns about your teeth?

Please list family members who have or are being treated with HVO

WILL YOU BE BRINGING ANY CURRENT X-RAYS TO BRING TO YOUR APPOINTMENT? *YesNoIf there is any possibility that you may be pregnant, please inform the staff.

PARENT/GUARDIAN 1 DETAILS

Select

Surname

Given Names

Date of Birth

Street Address

Suburb

State

Post Code

Work Phone

Home Phone

Mobile Phone

Email Address

Work Name

Occupation

Relationship to Patient

PARENT/GUARDIAN 2 DETAILS

Select

Surname

Given Names

Date of Birth

Street Address

Suburb

State

Post Code

Work Phone

Home Phone

Mobile Phone

Work Name

Occupation

Relationship to Patient

ACCOUNT DETAILS

Please indicate who will be responsible for the payment of accounts by percentage.

Self *Enter %

Parent/Guardian 1 *Enter %

Parent/Guardian 2 *Enter %

Other *Enter %

HEALTH DETAILS

Another (2nd) orthodontic opinion from us *YesNo

Previously treated with braces or plates *YesNo

Teeth extracted *YesNo

Damage to teeth *YesNo

Damage to face *YesNo

Jaw joint problems *YesNo

Tooth grinding habit *YesNo

Thumb or finger sucking habit *YesNo

Asthma *YesNo

Mouth breathing problems *YesNo

Sinus problems *YesNo

Migraine headaches *YesNo

Growth problems *YesNo

Physical disabilities *YesNo

Are you taking bone medication** *YesNo

Any medical conditions** *YesNo

Regular medications** *YesNo

Allergies to medications** *YesNo

Latex Allergy *YesNo

Do you smoke *YesNo

- if so, how many per day

** Medication/Medical Condition/Allergy Details