Title* Mr Master Mrs Ms Miss Dr

Gender* Male Female Non Binary

Given Name*

Surname*

Date of Birth*

Address*

Postcode*

Contact No*

Email*

Occupation

General Dentist

General Dental Practice

Have you previously worn orthodontic appliances or had orthodontic treatment?* Yes No

If yes, please give details

Have you ever had an accident involving teeth or jaw?* Yes No

If yes, please give details

Have you ever had clicking noises or pain in your jaw?* Yes No

If yes, please give details

Is there a possibility that you could be pregnant?* Yes No

I certify that the above medical history is accurate at this time. If there are future changes, I will inform the practice.* Yes No

How did you hear about us?*

Dentist

Family/friends

Google

Facebook

Social Media

Ads

Other

Have any of your family members had treatment with us? * Yes No

Do you have Private Health Insurance?* Yes No

If yes, please give details

Person responsible for paying for the orthodontic treatment *

Parent/guardian name if under 18 years of age

Date*

Medical history form for new patients