Child medical history

Personal details

First name *
Middle name *
Last name *
Sex *
Date of birth *
Home Address *
Suburb *
Postcode *
Parent Email *
Parent Mobile phone *
Parent phone 2 *
Relation to Patient *
Title *
First name *
Surname *

Person responsible for paying accounts

Title *
First name *
Surname *
Occupation *
Employment Status *
Billing Address *
Suburb *
Postcode *
Is responsible party Australian citizen? *
Is patient 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 patient ever had any of the following *
What medications patient is currently taking *
Is the patient pregnant? *
Does patient smoke? *
Do you have any allergies? *
If yes, what are the allergies?
Are there any other medical problems we should be aware of? *

Does the Patient *

have Pain or clicking in the jaw joints? *
have Chewing and swallowing difficulty? *
Grind their teeth? *
have a speech problem? *
Have teeth ever been injured due to an accidednt or a blows? *
If yes, when?
has patient ever sucked their thumb or fingers? *
if YES at what age did the patient stop?
When did you have your last Dental Check - Up
Do you have any outstanding general dental work to be completed?
Why have you brought your child come to see us? *

Family Background

Are there any other children in family?
Name
Age
Name
Age
Name
Age

Whom may we thank for referring you. *

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

By clicking submit you are agreeing to our privacy policy

Book your orthodonticconsultation

  • No-obligation chat with our specialist orthodontist about the best treatments for you
  • Talk about any worries or concerns
  • Discuss payment plans

By clicking submit you are agreeing to our privacy policy

Start your smile journey with Smile Style Orthodontics today!

We have three convenient consultation options for you to choose from: a free Invisalign® consultation, a one-on-one orthodontic consultation or a free remote consultation from home.

* Required Fields

By clicking 'Book Now' you are agreeing to our privacy policy.