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Book A Consultation
Treatments
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Smile Gallery
Patient Information
Join Our Team

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New Patient Information

New Patient Information

Patient's Personal details

Title*

Mr Mrs Miss M/s Dr Unspecified

First name*

Last name*

Sex*

Male Female Unspecified

Date of Birth*

Home Address*

Suburb*

Postcode*

Email*

Mobile phone*

Dental Information

Patient's Dental Practice Name*

Patient's Dentist Name*

Medical Information

Family Doctor*

Phone number*

Address of Doctor*

Patient's Medical and Dental History

Please check if you ever had any of the following*

Asthma

Anemia

HIV Aids

Hepatitis

Epilepsy

Rheumatic Fever

Diabetes

Psychiatric Care

Head or Face Injury

Hormonal Disorder

Bone Disorder

Emotional Disorder

Bleeding Disorder

Blood Disease

Hearing disorder

Heart Disease

None of the above

What medications is the patient currently taking?*

Is the patient pregnant?*

Yes No

Does the patient smoke?*

Yes No

Any allergies?*

Yes No

If yes, what are the allergies?

Are there any other medical problems we should be aware of?*

Pain or clicking in the jaw joints?*

Yes No

Chewing and swallowing difficulty?*

Yes No

Grind their teeth?*

Yes No

Have a speech problem?*

Yes No

Have any teeth ever been injured due to an accident or having received a serious blow?*

Yes No

If yes, when?

Has the patient ever sucked their thumb or fingers?*

Yes No

If yes, what age did the patient stop?

Has the patient ever had orthodontic treatment?*

Yes No

If yes, when finished?

When did the patient have their last Dental Check - Up?*

Does the patient have any outstanding general dental work to be completed?*

Does the patient play any contact sport?*

Yes No

If yes, what sport?

What is the primary concern prompting an Orthodontic consultation?*

Are you seeking a second opinion?*

Yes No

If yes, what were your reasons?

Person responsible for paying your accounts *

Myself Parent / Guardian

Full Name*

Occupation*

Employment Status*

Are you covered by private dental insurance?*

Yes No

Fund name*

Are you covered by the Medicare scheme?*

Yes No

Medicare Card Number*

Reference Number*

Medicare Expiry date (MM/YYYY)*

Are you an Australian citizen?*

Yes No

Title*

Mr Mrs Miss M/s

First name*

Last name*

Mobile number*

Occupation*

Employment Status*

Relationship to Patient*

Billing Address*

Suburb*

Postcode*

Are you an Australian citizen?*

Yes No

Are you covered by private dental insurance?*

Yes No

Fund name*

Medicare Card Number*

Reference Number*

Medicare Expiry date (MM/YYYY)*

Do you have any other children in the family?*

Yes No

Name

Age

Name

Age

Name*

Age

The Family Care Program

Orthodontic problems often run in families. As a courtesy to our patients, we are happy to offer a complimentary consultation to "other" family members.

Whom may we thank for referring you?*

My Dentist (Name and practice) *

Family / Friend (Name) *

School newsletter (Name) *

Google *

Other

What type of treatment are you seeking?*

If treatment is deemed necessary, what is your ideal initial payment*

If treatment is deemed necessary, what is your ideal weekly payments?*

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Why we’re the clear choice for your treatment

Trust the team at SmileStyle Orthodontics to deliver the smile results you want.

1.

1,000 happy smiles created with Invisalign®

We are your local Diamond Invisalign® providers.

2.

Two convenient locations and easy parking

Come visit us in Loganholme or Capalaba.

3.

Excellent results for the whole family

It’s never too late to achieve your dream smile.

4.

State-of-the-art technology

We use the latest equipment to bring you the best results.

5.

30 years of specialist experience

We can treat even complex orthodontic issues at our practice.

6.

No deposit, no interest payment options

We keep a straight smile attainable on any budget.

Meet Dr Tselepis Meet our team

Loganholme
Capalaba

70 Bryants Road Loganholme Queensland 4129 Australia

enquire@michaeltselepis.com

Monday - Friday: 8am - 5pm
Wednesday: Closed
Saturday: Closed
Sunday: Closed

Suite 4 76 Old Cleveland Rd Capalaba Queensland 4157 Australia

enquire@michaeltselepis.com

Wednesday only:: 8am - 5pm

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