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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Child Medical Form

Name: Profile Orthodontics
Telephone: 08 9300 9975

(To be completed by a parent / guardian if the patient is under 18 years of age)

In order to provide you with the highest standard of orthodontic care, it is important to know the patient’s medical and dental history, as these could affect the success of the 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 information please read our privacy policy – ‘We Respect Your Privacy’.

Fields marked * are required.

Patient Information

Title *

Master

Miss

Gender *

Male

Female

Non Binary

First Name *

Last Name *

Home address *

Suburb *

Postcode *

Date of Birth *

School *

Patient’s Email same as parent/guardian *

Home Phone Number *

Parent or Guardian Contact Details

Parent 1

Title *

Mrs

Miss

Gender *

Male

Female

Non Binary

First Name*

Last Name*

Mobile Number

Work Phone Number

Parent 2

Title *

Mrs

Miss

Gender *

Male

Female

Non Binary

First Name*

Last Name*

Mobile Number

Work Phone Number

Guardian

Title *

Mrs

Miss

Gender *

Male

Female

Non Binary

First Name*

Last Name*

Mobile Number

Work Phone Number

Referral Information

Please fill in applicable referee

Whom may we thank for referring you? *

Dentist Name

Phone Number

Location

Doctor 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

Person/s responsible for account payment:

Relationship to Patient *

Parent 1

Parent 2

Parent 1 & 2

Guardian

Other

If other, specify relationship

Full Name*

Phone

Billing Address

Medical & Dental History

What is your main reason for seeking this consultation?

Are there any medical aspects you wish to discuss in private (without the patient)?

Yes

To assist with assessing growth, has the patient commenced puberty?

Yes

Has the patient inherited any facial or dental characteristics?

Yes

If yes, please give details

Does the patient take any regular medication? (prescribed, over the counter or naturopathic/herbal)?

Yes

If yes, please give details

Does the patient have any allergies to any medicines, chemicals, foods, or other substances (eg rubber, latex, antibiotics, peanuts etc)

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 behavioural concerns or anxiety that may inhibit orthodontic treatment?

Any previous orthodontic consult by a dentist/orthodontist?

Yes

Any previous orthodontic treatment?

Yes

If yes, please give details

Any injury to the baby or 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)

Sucked their thumb, finger or similar habit?

Experienced pain from the jaw joint or facial muscles?

Experienced severe headaches or migraines?

Experienced clicking, popping or grating sound from the jaw joint?

Patient Acknowledgement

Name of person completing this form *

Today's Date *

Please 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