Patient Personal & Medical Questionnaire

Kindly fill in the Patient Medical Questionnaire form below

 

Fields marked * are required.

The state of your health may have a significant effect on your orthodontic care.

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

Dental history

Orthodontic concerns

DECLARATION

  • 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.

The Invisible Orthodontist

American Association of Orthodontists

Invisalign

Invisalign teen

Find Us

Blacktown Practice
Suite 804 Westpoint Towers 17 Patrick St
Blacktown New South Wales 2148
Australia

(02) 9676 3400 Direction & opening Times

Find Us

Dubbo Practice
60 Bultje Street
Dubbo New South Wales 2830
Australia

(02) 6885 2110 Direction & opening Times