New Patient Registration Form

PATIENT DETAILS

First Name *

Last Name *

Preferred Name

Date of Birth *

PARENT OR GUARDIAN DETAILS *** skip this field if you are booking for yourself

MrMrsMs

Parent First Name

Parent Last Name

Relationship to Patient

MotherFatherGuardianOther

PATIENT CONTACT DETAILS

Address *

City / Suburb *

State *

Postcode *

Mobile Phone *

Home Phone

Email *

YOUR INTEREST IN ORTHODONTIC TREATMENT

What type of orthodontic appliances are you interested in? *

Do you currently have braces (started from other doctors) and want to continue a treatment with us?

YesNo

What is your "Main Concern" eg. crooked teeth, spacing, bite problem or jaw position?

When are you looking to start? *

Comprehensive Orthodontic treatment cost can range from $6500.00 - $10,500.00, we offer pay in full discounts and payment plans. Do you require information on payment plan or pay in full discounted price? *

Payment planPay in full

HOW DID YOU HEAR ABOUT US

Dentist First Name

Dentist Lastname

Dentist's Clinic Name

Friend or family who referred? or name of school?

New Patient Medical History Questionaire

EMERGENCY CONTACT *

Contact number *

Dental history

How often do you brush your teeth? *

OnceTwice3 timesNever

How often do you floss? *

OncetwiceNight time onlyDo not floss

MEDICAL HISTORY

Other conditions? If none type "None" *

Other allergies? If not please write "No Allergies" * *

Do you smoke? *

YesNoUsed to

Lastly, would you like to be a part of a social media transformation journey which will help us help future patients? ($280.00 discount for this option) *

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Today's Date

Patient/ Guardian Signature

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