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Balwyn Practice Doreen Practice 03 9817 6427 Contact us Refer to us

Free Consultation
Invisalign®
Treatments
Meet the Team
Smile Gallery
Cost & Finance
Patient Information
News

Book a free* consultation

Name *

Email *

Phone *

Preferred Location *

For further information about how we use your data, please see our privacy policy

Book a free consultation

Name *

Email *

Phone *

For further information about how we use your data, please see our privacy policy.

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New patient form

Name: Angle House Orthodontics
Telephone: 03 9817 6427

To ensure we have all the information we need for your first visit, please fill out the appropriate health history form below and bring this with you on the day.

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Patient Information
New patient form

Fields marked * are required.

Patient Information

Title* Dr Mr Mrs Miss Ms Master Other

Preferred Name*

Surname*

Given Name (as per passport/Medicare card)*

Preferred Pronoun* He She They Not listed

If not listed, please give preferred pronoun

Gender Identification* Male Female Non Binary

Address*

Postcode*

Phone Home

Mum/Dad Phone

Emergency Contact

Email*

Date of Birth*

School/Occupation*

Regular Dentist Name

Dentist Phone

Dentist Email

Dentist Suburb

Private Health Fund*

Medicare Number*

Position on Card*

Medicare Number Expiry date*

How did you hear about our practice?*

Dentist

Website

Friend

Family

Signage

Social Media

Other

Have any other family members attended these rooms* Yes No

If yes, please give name

What concerns you most about your teeth?*

Billing Information

(If Child) Mother’s full name

Father’s full name*

Name and address of person responsible for account*

Correspondence addressed to

Medical Information

Have you ever had any of the following?*

Diabetes

High/Low Blood Pressure

Heart Ailment

Tonsils/Adenoids Removed

Tuberculosis

Stomach/Bowel Problems

Kidney Disease

Excessive Bleeding

Rheumatic Fever

Asthma/Breathing Problems

Epilepsy

Thyroid Problems

Hepatitis

HIV/AIDS

Learning Difficulties

Are you a smoker?* Yes No

Do you have an artificial hip, heart valve or other prosthetic implant?* Yes No

Are you presently under medical care?* Yes No

If yes, please explain

Are you presently taking any medication?* Yes No

If yes, please list

Do you have any known allergies? Yes No

If yes, please list

List any other previous illnesses

Have you ever had problems with dental treatment?

Female patients, are you pregnant?* Yes No

Would you like to discuss these questions in private with your Orthodontist?* Yes No

I have completed this Questionnaire to the best of my knowledge and understand that failure to make a full disclosure may place ME at undue risk. I understand that notes, radiographs (xrays) or models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this. I also give my permission for the practice to use the above contact details to send appointment and check up reminders.

I give my consent for xrays, models and photographs to be used for marketing, research and continuing education purposes Yes No

I am happy for Angle House to contact me via email with regard to practice news and other initiatives Yes No

Date*

Please sign here: