DENTISTS REFERRALS

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New Patient Form

Are you ready to transform your smile or the smile of your loved one? Fill out the form below so we can set that smile up for success with a fully bespoke orthodontic treatment.

New Patient Form

Patient details

Gender*

Male

Female

Prefer not to answer

Not listed

Preferred Pronoun*

He

She

They

Prefer not to answer

Not listed

Age

DOB

First Name*

Last Name*

Address*

Suburb*

Postcode*

Phone*

Mobile

E-mail*

Occupation/School

Emergency Contact*:

Responsible party Name

Same as above

Gender

First Name*

Last Name*

Address

Postcode*

Phone*

Mobile*

Email*

Relation

Do you have private health insurance?*

Yes

No

If yes, which fund?

Dental History

Name of Dentist & Address

Is this your first visit to an orthodontic practice?

Yes

No

Has the patient had a dental check-up within the last 12 months?

Yes

No

Are you happy with your smile?

Yes

No

Does dental treatment make you nervous?

Yes

No

Do you grind your teeth or suffer from headaches?

Yes

No

Have you ever had any problems with dental treatment?

Yes

No

Do you suffer from gastric reflux?

Yes

No

Gastric reflux - if yes, describe?

Do you suffer from snoring or sleep apnoea?

Yes

No

Medical History

Doctor's Name

Phone

Have you had any of the following?

Rheumatic Fever

Tuberculosis

Excessive bleeding

Blood disease

Arthritis

Epilepsy

Diabetes

High Blood Pressure

Hepatitis or HIV

Asthma

Heart Ailment

Liver or Kidney Disease

Other Medical Problems

If other, details

Are you currently under medical care or taking any medication?

Yes

No

If yes, what?

Are you currently taking osteoporosis medication?

Yes

No

Are you allergic to any drugs, medicines or latex?

Yes

No

If yes, what?

Is there a possibility that you could be pregnant?

Yes

No

How did you find out about Frankston Orthodontics? (Please tick as many as appropriate)

Recommended by someone

Referred by dentist

Saw the practice from the street

Brochure

Our Website

Yellow Pages book

yellowpages.com.au

Flyer or postcard in mail

Advertising in local newspaper

Other advertising

Google

Bing

Yahoo

invisalign.com.au

hotfrog.com.au

truelocal.com.au

findnearest.com.au

seeklocal.biz

Other

If Any Other, describe?

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Start your smile journey at Frankston Orthodontics today.

1 Playne Street,
Frankston
VIC 3199

Monday - Friday 08:30 - 17:00

Saturday by special appointments

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