Personal and Contact Information (Patient Details)

Title* Mr Mrs Miss Ms Dr Other

Gender* Male Female Non Binary

First Name*

Last Name*

Address*

Suburb*

Postcode*

Date of Birth*

Phone*

E-mail*

School Name (if applicable)

Please list your Orthodontic Concerns*

How did you hear about us*

Health Fund Details (if applicable)

Do you have a referral from your dentist* Yes No

Dentist Name

Dentist Phone

Dentist Email

Dentist Suburb

Family members who attend Evolution Orthodontics

Which treatment are you interested in* Braces Aligners

Before your consultation, please check with your health fund to see if orthodontic treatment is covered.
If you're considering braces, the item number is 831 x 2.
If you're considering aligners, the item number is 825 x 2.

Billing / Responsible Party

Is the patient responsible for the account (must be over the age of 18)* Yes No

If No, enter details below:

Title* Mr Mrs Miss Ms Dr Other

Are you Australian citizens Yes No

First Name

Last Name

Date of Birth

Email

Address

Suburb

Postcode

Mobile

Dental and Medical History

Are you receiving any medical treatment at present* Yes No

Have you had Orthodontic Treatment Previously* Yes No

If Yes, please provide details

Is this a second orthodontic opinion* Yes No

Last Dental visit date and reason

Details of any past injury/surgery to the face/teeth/jaws

List any medications you are currently taking*

Do you have any allergies* Yes No

If Yes, list any allergies (especially to latex, antibiotics, penicillin, local anesthetics, nickel, iodine, sulphur, aspirin and any food allergies

Please tick if you have ever had any of the following:*

Person who filled the form (if patient is under 18 years of age)* Myself Other

If Other, please provide details

Name of person who filled the form

Relation to patient

In signing this form I acknowledge that this represents an accurate medical history. I will advise my orthodontist of any changes to my medical history in the future.
I understand that all medical details will be treated with complete professional confidentiality.
I have read the privacy document provided by this practice.

Date*

Blacktown

Dubbo

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Personal and Contact Information (Patient Details)

Billing / Responsible Party

Dental and Medical History

Please tick if you have ever had any of the following:*

DECLARATION

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