Patient detailsTitle*Select TitleMrMrsMsMissMasterDrName* First Last Gender*Select GenderMaleFemaleDate of Birth* Address* Street Address Address Line 2 City State Zip Code Phone (Home) Phone (Work)Mobile*Email* Medicare Number* Number on Medicare Card* Expiry Date* 1. Who recommended that you seek a consultation here?* 2. Have any other members of your family had orthodontic treatment? 3. Mother’s Name Father’s Name 4. How many brothers and sisters do you have? (i) Name Date of Birth DD slash MM slash YYYY (ii) Name Date of Birth DD slash MM slash YYYY (iii) Name Date of Birth DD slash MM slash YYYY 5. Who is responsible for the payment of fees?* Address* Street Address Address Line 2 City State Zip Code 6. Do you have private health insurance for orthodontic treatment?*YesNo(i) If yes, who is the health fund? 7. Who is your dentist?* First Last Address Street Address City State Zip Code 8. Who is your doctor? First Last Address Street Address City State Zip Code 9. What concerns you the most about your teeth?* 10. School/Occupation* If you answer “Yes” to any question 11-24 please provide details in the space provided11. Have you had your teeth checked in the last 12 months?*YesNoIf "Yes" please provide details 12. Have you been to see another orthodontist?*YesNoIf "Yes" please provide details 13. Are you currently having orthodontic treatment which was commenced at another practice?*YesNoIf "Yes" please provide details 14. Have you ever undergone orthodontic treatment in the past?*YesNoIf "Yes" please provide details 15. Have your teeth or jaws ever been damaged in an accident?*YesNoIf "Yes" please provide details 16. Do you suffer from pain, clicking, limitation of movement or locking of your jaw joints?*YesNoIf "Yes" please provide details 17. Have you ever had a serious medical or surgical problem?*YesNoIf "Yes" please provide details 18. Have you taken antibiotics for a period longer than 3 months?*YesNoIf "Yes" please provide details 19. Are you currently taking any medication?*YesNoIf "Yes" please provide details 20. Do you have any allergies (especially to drugs or medications)?*YesNoIf "Yes" please provide details 21. Females: are you pregnant?YesNoIf "Yes" please provide details 22 Do you suffer from (or have you ever had) any of the following?* Rheumatic Fever Heart disease High blood pressure Stroke Rheumatism Asthma Diabetes Fits/Epilepsy Kidney disease Hepatitis Any blood disorder Disorder of the stomach, bowel or digestive system Intellectual disabilities/Special needs Autism spectrum Snoring None of the above If "Yes" please provide details 23. Are there any further health issues that we should be aware of?*YesNoIf "Yes" please provide details 24. Do you have any reason to believe that you may be in an ‘at risk group’ to AIDS or Hepatitis B?*Yes – Please advise the orthodontist at the consultationNoI acknowledge I have filled in this form to the best of my knowledge and ability, as honestly and correctly as possible. Therefore, I give my consent for HiTech Ortho to care for the patient for his/her oral health needs* Yes No EmailThis field is for validation purposes and should be left unchanged. Δ