BOOK A CONSULTATION
(03) 4505 2524

Patient Information Form

Patient Information Form

Name: Warrnambool Orthodontics
Telephone: (03) 4505 2524

Please complete the below forms before your consultation so we can have this information ready before you begin treatment.

Patient details

First Name (Legal Name)*

Last Name*

Preferred Name*

Date of Birth*

Gender* Male Female Other

Preferred Pronoun* He/Him She/Her They/Them

Home Address*

Postcode*

Home Phone

Work Phone

Mobile Phone*

Email Address*

Patient’s School / University

Parent (s) or Guardians' names (If patient is under 18 years)

Patient lives with* Parent(s) Mother Father Self Other

Family Dentist

Who may we thank for referring you to our practice?

Medicare Number*

Reference Number*

Expiry

Are you covered for Orthodontic Treatment by private health insurance?* Yes No

If so, name of Insurer:

Responsible Party Information (The Person who is responsible for paying for your treatment)

First Responsible Party

First Name (Legal Name)

Last Name

Date of Birth

Relationship

Home Address (if not same as above)

Postcode

Phone No

Second Responsible Party

First Name (Legal Name)

Last Name

Date of Birth

Relationship

Home Address (if not same as above)

Postcode*

Phone No

Emergency Information

Contact Person*

Relationship*

Phone No*

General Information

Has the patient had an orthodontic consultation before?* Yes No

If “yes”, with whom:

Has the patient ever had orthodontic treatment? * Yes No

If “yes”, with whom and what was the treatment?

Any medical conditions or allergies? *

Current medication list *

Have you had any problems with dental treatment? * Yes No

If “yes”, please describe

Have any other family members had orthodontic treatment with us? * Yes No

If “yes”, what is the patient’s name?

I understand that the above information will be kept strictly confidential.

Date

Signature (Parent’s signature if under 18 years)

Find Us

171a Liebig St
Warrnambool
VIC 3280

(03) 4505 2524

Hours

Monday 8:30am-5pm
Tuesday 8:30am-5pm
Thursday 8:30am-5pm
Friday 8:30am-5pm

BOOK A CONSULTATION

PRIVACY POLICY
TERMS & CONDITIONS
COOKIES POLICY