Patient Name
|
First: *
|
Middle:
|
Last: *
|
Home Address
|
Street: *
|
Line 2:
|
City: *
|
State/Province/Region:
|
Zip/Postal Code:
|
Country:
|
Postal Address (if different from Home Address)
|
Postal Address:
|
Postal Address (Zip/Postal Code):
|
Home Phone: *
|
Patient D.O.B.: *
|
Parent / Caregiver 1 Name
|
First: *
|
Last: *
|
Phone: *
|
Email: *
|
Parent / Caregiver 2 Name
|
First:
|
Last:
|
Phone:
|
Email:
|
Name of Patient's School/Polytechnic/University:
|
Name of Referring Person
|
First:
|
Last:
|
Patient's Dentist/School Dental Therapist:
|
Preferred clinic location: *
|
Medical Questions
|
Is the patient currently taking any medicines or tablets? *
|
Does the patient have any infectious diseases at present? *
|
Has the patient got any other serious illnesses at present? *
|
Is the patient in the high risk group for Hepatitis? *
|
Does the patient have a bleeding disorder? *
|
Is the patient allergic to anything? *
|
Has the patient been in hospital or had any medical treatment in the last 6 months? *
|
Has the patient ever had any accidents or operations involving the mouth or face? *
|
As an X-ray may be taken, is the patient pregnant? *
|
Is there any other health matter that you would like to discuss with the Orthodontist? *
|
If you answered Yes to any of the above questions, please add notes here:
|
Has the patient ever had any of the following?
|
Rheumatic Fever: *
|
Heart Trouble: *
|
High Blood Pressure: *
|
Glandular fever: *
|
Anaemia: *
|
Arthritis: *
|
Bronchitis or Chest Problems: *
|
Severe Headaches: *
|
Epilepsy: *
|
Diabetes: *
|
Glaucoma: *
|
Cold Sores: *
|
Stomach Problems: *
|
Thyroid disorders: *
|
Depressive Illness: *
|
Drug Dependence: *
|
If you have said Yes to any of the above, please add any notes about this condition here:
|
Confirmation:
By typing my name out below I am acknowledging that all the above medical information is true to my knowledge. I will settle all accounts from BP Orthodontics Trading as The Orthodontist within a reasonable period of time. If not, I acknowledge that I will be liable for interest/debt collection fees or other fees which may be involved in the recovery of any outstanding debt.
|
First Name: *
|
Last Name: *
|
Month: *
|
Day: *
|
Year: *
|
We can't wait to see you. Is there anything else you would like to ask or know?
|
|
|
