New Patient Information

Please complete this form before your first visit. It takes about 5 minutes. Fields marked * are required. If the patient is under 18, a parent or guardian should fill it in.

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Patient details

Title First name Middle name Surname

Would like to be calledpreferred or nickname, if different Date of birth Name as it appears on Medicare card

Health fund (Private Health Insurance)No Health Fund

Street addressstart typing your street address

Suburb

State Postcode

Mobile Home phone Work phone Email Confirm email

Parent / guardian

Required if the patient is under 18. Add more parents / guardians with the button below.

About the patient

School year / occupation School Workplace / university When did you last notice a growth spurt?e.g. grew a lot over the last 6 months, not sure

Has anyone in the family had orthodontic treatment?

YesNoNot sure

Who?e.g. older sister, Mum Treated by (if you remember)orthodontist or practice

Medical history

Are you taking any regular medications?

YesNo

Please list them

Do you have any significant medical conditions? (e.g. heart conditions, bleeding disorders, organ disease, asthma, diabetes)

YesNo

Please specify

Do you have any allergies?

YesNo

Please specifye.g. penicillin, latex, nickel

Any operations or hospital stays?

YesNo

Tonsils / adenoids removedWisdom teeth removedOther dental surgeryOther operation / hospital stay

Details (what and when)

Are you pregnant?

YesNoNot applicable

Dental history

Do you have a regular dentist?

YesNo

Dental practice Dentist's name Practice phonefills in when you pick a practice or dentist Practice addressfills in when you pick a practice or dentist

How often do you visit your dentist?

Every 0–6 monthsEvery 6–12 monthsMore than 12 monthsOther

Your treatment

What are your main concerns about your teeth? (tick any)

Crooked / overlapping teethTeeth not coming through / impacted / missing teethGaps between teethUpper front teeth stick outDeep bite / overbiteUnderbite / lower jaw sits forwardCrossbiteOpen bite (front teeth don't meet)Jaw or facial profileSmile not centred (midlines)High or sticking-out canine teethTeeth have moved since previous bracesJaw pain / clicking / grindingDentist recommended a checkWant a second opinionInterested in clear aligners

Anything else about your concerns?

What would you like to achieve with orthodontic treatment? (tick any)

Straighter smileClose gapsFix my biteEasier to clean / healthier teethMore confident smileImprove facial profilePrevent problems later onJust want advice for now

Anything else you'd like to achieve?

Preferred payment option

Up-front paymentMonthly payment planNot sure yet

How did you hear about us?

Dentist referred

Referring practiceReferring dentist

Current / former Attractive Orthodontics patient

Family / friends

Mail drop / newspaperSchoolGoogle / website / social mediaDriving past

Where did you see us? (tick any)Google searchGoogle MapsOur websiteTikTokFacebookInstagram

Other

Confirm and sign

Attractive Orthodontics collects this information to provide orthodontic care, contact you and manage your account. It is sent securely to our practice only and handled under the Privacy Act 1988 and our privacy policy. You can ask to see or correct it at any time.

Full name of person completing this form Relationship to patient

I confirm the information above is correct to the best of my knowledge, and I consent to Attractive Orthodontics collecting and using it as described above.

Signature

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I acknowledge that ticking this box and typing my full name above is my electronic signature for this form.

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We'll email a 6-digit code to the address above. Or untick the box and download your copy after sending.

Date:

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