Medical Forms – Breakdance Test

Preferred practice location*

Geelong

Hoppers Crossing

Gender*

Male

Female

Prefer not to answer

Not listed

Preferred Pronoun*

He

She

They

Prefer not to answer

Not listed

Patient's First Name*

Patient's Last Name*

Date of Birth*

Home Address*

Suburb*

Postcode*

Phone No (H)*

Phone No (W)*

Phone No (M)*

Email Address*

Patients School / University

If patient is a minor, please give parent(s) or Guardian’s names:

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

Family Dentist

Who referred you to our practice?

Do you have a Medicare?**

Yes

No

If so, name of insurer*

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

The payment plans we offer are based on the information you provide below and are designed to help you.
If you do not wish to complete this section below, then we shall be very limited in the financial arrangements we can offer you.

Or, please provide details if responsible party is different to patient:

First Responsible Party Details

Responsible Party First Name

Responsible Party Last Name

Date of Birth

Relationship

Home Address

Postcode

Phone No (H)

Phone No (W)

Phone No (M)

Employer/s

Occupation/s

Second Responsible Party Details

Responsible Party First Name

Responsible Party Last Name

Date of Birth

Relationship

Home Address

Postcode

Phone No (H)

Phone No (W)

Phone No (M)

Employer/s

Occupation/s

Other than the responsible parties listed above, are there any other individuals or legal guardianship arrangements, in place that require specific consent for the patient to elect treatment and/or who need to be involved in the ongoing management of the orthodontic treatment?*

Yes (Our team will require a supplementary form to be completed)

No

Emergency Information

Contact Person

Relationship

Phone No (H)

Phone No (W)

Phone No (M)

General Information

Has the patient had an orthodontic consultation before?*

Yes

No

Has the patient ever had orthodontic treatment?*

Yes

No

Any medical/behavioural conditions, allergies or illnesses?*

Yes

No

Have you had any problems with dental treatment?*

Yes

No

Have any other family members had orthodontic treatment with us?

Yes

No

Are you taking any prescribed medication/s?

Yes

No

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

Please sign here:

Patient medical forms