Patient Name
Home Address
Age
Birthdate
Sex
Home Phone
Work Phone
Email Address
Title and Full name
Name(s) of other family member(s) treated by us
Title and Full name
Emergency Contact Full Name
Occupation
Phone
Occupation
Phone
Phone
⃝
⃝De Facto
De Facto
⃝Single⃝Separated/Divorced
Single⃝Separated/Divorced
Single⃝Separated/Divorced
⃝Separated/Divorced
Separated/Divorced
⃝ (Court order in place Y / N )
Court order in place Y / N )
⃝Single⃝Separated/Divorced
Court order in place Y / N )
Occupation:
Occupation:
Phone:
Phone:
Email:
Email:
to patient information (for example; Grandparents, Personal Assistants, Nannies, etc.):
Full name:
orkplace:
orkplace:
ent:
⃝ Rheumatic fever
heumatic fever
⃝ Bleeding disorders
Bleeding disorders
⃝ Heart disease
⃝ HIV/AIDS
⃝ Hepatitis
⃝ Psychological disorders
⃝ Kidney disease
⃝ Breathing difficulties
⃝ Diabetes
⃝ Birth defects
⃝ Growth problems
⃝ Snoring, Sleep apnoea etc.
⃝ Asthma
⃝ Speech problems or similar
⃝ Othe
⃝ Learning difficulties
⃝ Asthma
Any allergies:
⃝ Asthma
What dental treatment has the patient had?
Were there any difficulties with treatment?
⃝ Asthma
Have there been any accidents involving the teeth or jaws?
Is there family history of tooth root shortening?
Has the patient had orthodontic treatment before?
Date:
⃝ Yes ⃝ No
Yes ⃝ No
Yes ⃝ No
⃝ No
No
⃝ Yes ⃝ No
Signature
Back
Next
Signed
Date
Patient/ Parent / Guardian Name
Name of patient
Should be Empty: