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Please fill out this form so we can provide you with the best orthodontic care.
Patient contact information
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Gender
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Other
School name or occupation
Mobile Phone
Postal address
Street Address
Address Line 2
City
Postcode
How did you hear about us?
Dentist
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Website
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Cleft Clinic
N/A
Does the child live with (under 18yrs only)
Mother only
Father only
Both parents
Other
When did you last visit the dentist?
Medical history
Name of your family dentist
Are you taking any tablets, medicines, pills or drugs?
If yes, please list below
Have you ever had an allergic reaction to medicines, or other substances such as latex?
Yes
No
Have you ever had contact with
HIV virus
Hepatitis B
Hepatitis C
N/A
Are you pregnant?
No
Yes
Do you smoke/vape?
No
Yes
Have you ever had any of the following?
Heart Murmur
Rheumatic Fever
Open heart surgery
High blood pressure
Stroke
Other
N/A
Please provide details
Is there anything else we should know about in order to take good care of you or your child?
Eg allergies, medical history, custody arrangements, special needs.
Please provide details
Account holder details (must be over 18 years)
Name
First
Last
Phone
Email
Relationship to patient
Address (if different from above)
Street Address
Address Line 2
City
Postcode
Place of work
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Signature
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