WELCOME TO THE PRACTICE
Patient’s Surname:
Patient’s First name:
Title: Mr / Mrs / Miss / Ms / Master / Dr
Preferred Name:
Referred by:
Usual Dentist:
Date of Birth:
Sex: M F
Home Address:
Mailing Address: (if different)
Suburb:
Postcode:
Telephone
Home:
Work:
Mobile:
Person Responsible for Payment
Self Mother Father
Other:
IF APPLICABLE
School/University:
Mother’s name in full:
Mother’s Title: Mrs / Miss / Ms / Dr / Other
Father’s name in full:
Father’s Titile: Mr / Dr / Other
Email Address:
What is your main concern about your teeth/bite:
MEDICAL HISTORY (Please indicate any of the following)
Diabetes Rheumatic Fever HIV/AIDS
Epilepsy Endocrine Problems Hepatitis
Asthma Cold Sores/Herpes Tonsil Removal
Fainting Bone Disorder Adenoid Removal
Heart Condition Excessive Bleeding
Any relevant details:
Current Medications:
ALLERGIES:
DENTAL HISTORY
Past injuries to face:
Thumb/finger sucking:
Mouth breathing:
Teeth grinding:
Extra or missing teeth:
Have any family members had braces:
Has an Orthodontist been consulted previously? Yes No
Health Fund:
Sports and Hobbies:
Other relevant information:
If x-rays are required I . (parent guardian) consent to the taking of all radiographs.
Thank you
All records may be used for teaching purposes.
This information will be treated in accordance with the organisations privacy policy.
DR DAVID MASTROIANNI BDS (SYD), DCD (MELB), MORTH RCSED | SPECIALIST ORTHODONTIST
MY ORTHO PTY LTD | 143 ALISON RD RANDWICK NSW 2031 | P (02) 9399 6897 | F (02) 9399 9442 | E info@myortho.com.au | W myortho.com.au