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


  • 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 teen

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

(02) 9676 3400 Direction & opening Times

Find Us

Dubbo Practice
60 Bultje Street
Dubbo New South Wales 2830

(02) 6885 2110 Direction & opening Times