Adult medical history

Personal details

Title *
First name *
Middle name *
Last name *
Sex *
Date of birth *
Home Address *
Suburb *
Postcode *
Email *
Mobile phone *
Home phone *
Occupation *
Employment Status *
Are you an Australian Citizen? *
Are you covered by dental insurance? *
Fund Name *

Medical Information

Family Doctor *
Address of Doctor *
Suburb *
Postcode *
Patient's dentist *
Date last seen by dentist *

Patient's Medical and Dental History

Please check if you ever had any of the following *
What medications are you currently taking? *
Are you pregnant? *
Do you smoke? *
Do you have any allergies? *
If yes, what are the allergies?
Are there any other medical problems we should be aware of? *
Pain or clicking in the jaw joints? *
Chewing and swallowing difficulty? *
Grind your teeth? *
Have you teeth ever been injured due to an accident or having received a serious blow? *
If yes, when?
When did you have your last Dental Check - Up
Do you have any outstanding general dental work to be completed?
Why have you come to see us? *
Other

Person responsible for paying your accounts *

Whom may we thank you for referring you. *

My Dentist (Name and practice)
Family / Friend (Name)
School newsletter (Name)
Newspaper advertisement (Name)
Other

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Free Invisalign® consultation

See your future smile with a complementary scan at your free Invisalign® consultation. Our Treatment Coordinator will talk you through our treatment and payment options, and there is never any obligation to move forward with treatment.

Orthodontic consultation

Book a consultation with our very own Specialist Orthodontist, Dr Tselepis, who will examine your smile and create a completely bespoke treatment plan for your smile goals. We’ll even give you time to ask questions, so you feel confident in your choice to start treatment with us.

Remote consultation

Take the first step to a straighter smile from the comfort of home with a remote consultation. Just fill out the form and upload photos of your smile, and will get right back to you with our treatment recommendations.