REFERRALS

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Joondalup08 9300 9975 Cottesloe(08) 9284 3222

REFERRALS

Joondalup 08 9300 9975

Cottesloe (08) 9284 3222

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- Joondalup
- Cottesloe

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Adult Medical Form

Name: Profile Orthodontics
Telephone: 08 9300 9975

In order to provide you with the highest standard of orthodontic care, it is important to know your medical and dental history, as these could affect the success of your treatment. Please do not hesitate to ask if you have any questions associated with the information we collect from you and hold in your records. We are acting in your best interest at all times. For further infhormation please read our privacy policy – ‘We Respect Your Privacy’.

Fields marked * are required.

Patient Details

Title *

Mrs

Miss

Master

Gender *

Male

Female

Non Binary

First Name*

Last Name *

Home address *

Suburb *

Postcode *

Date of Birth *

Place of work/study *

Mobile Number *

Home Phone Number *

Work Phone Number *

Email Address *

Emergency contact

First Name

Last Name

Phone Number

Referral Information

Please fill in applicable referee

Whom may we thank for referring you? *

Dentist’s name

Phone Number

Location

Doctor’s name

Phone Number

Location

How did you hear about Profile Orthodontics

Friend/family who recommended us

Please let us know Who

How did you discover Profile Orthodontics? *

Internet

Website

Social media

Sponsorship

Other

Have any other family members who had attended the practice *

Yes

If Yes, Please add details Names/relationship

Private Health Fund

Do you have private health insurance? *

Yes

If yes, Fund Name

Financial Information

Is the patient responsible for the account?*

Yes

If NO, please continue with this section:

Relationship to Patient*

Title *

Mrs

Miss

Master

First Name

Last Name

Mobile Number

Home Phone Number

Work Phone Number

Address

Medical & Dental History

What is your main reason for seeking this consultation?

Do you have private information you wish to discuss with the Orthodontist and not record on this form?

Yes

Are you allergic to any medicines, chemicals, foods, or other substances (eg rubber, latex, antibiotics, peanuts)

Yes

Do you have any inherited any facial or dental characteristics? *

Yes

If yes, please give details

Do you take any regular medication? (including prescribed, over the counter or naturopathic/herbal)?

Yes

If yes, please give details

Please tick ONLY if you have, or have ever had, any of the following medical conditions:

Heart disease/complaint or heart murmur

Liver or Kidney problems

Anaemia, Leukaemia or other blood disorders

Asthma or Lung Disease

Diabetes

Hepatitis A, B or C

Rheumatic Fever

High or low blood pressure

Bleeding problems

Growth problems

Autism

Scoliosis or Bone Disorder

Sleep disordered breathing, snoring

mouth breathing or nasal obstruction

Arthritis

Epilepsy

Tonsils or adenoids removed / other ear, nose and throat problems

Speech and hearing problems

Cerebral Palsy

Any other current or previous medical conditions or health problems? (please list)

Any previous orthodontic consult by a dentist/orthodontist?

Yes

Any previous orthodontic treatment?

Yes

If yes, please give details

Any injury to your permanent teeth?

Yes

If yes, please give details

Had any injury to your face, jaws, forehead, nose or chin?

Yes

If yes, please give details

Have you ever experienced? (tick applicable)

Headaches or migraines?

Clicking, popping or grating sound from your jaw joint?

Pain from your jaw joint or facial muscles?

Patient Acknowledgement

Name of person completing this form *

Today's Date *

Sign here: *

For further information about how we use your data, please see our privacy policy.

Visit us

Our specialist orthodontic practices are located in two convenient locations.

Select A Location

Joondalup
Cottesloe

Profile Orthodontics Joondalup

3 Shenton Avenue (cnr Lakeside Drive),
Joondalup WA 6027

08 9300 9975

info@profileorthodontics.com.au

Opening Hours

Monday - Friday: 8.15am - 5.00pm

Get Directions on Google Maps

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Profile Orthodontics Cottesloe

30 Jarrad Street (cnr Railway Street),
Cottesloe WA 6011

(08) 9284 3222

info@profileorthodontics.com.au

Opening Hours

Tuesday - Friday:: 8.15am - 5.00pm

Get Directions on Google Maps

DISCOVER MORE

PRIVACY POLICY
TERMS & CONDITIONS
COOKIES POLICY