Home
About Menai Orthodontics
- Dr Sarah Dan
- Dr Michael Counsel
Treatment
Gallery
Finance
Resource Centre
Contact Us

Suites 21 & 22, Level 1
62-70 Allison Crescent
Menai NSW 2234

02 9543 3680 0481 609 848 Dentist Referral Book Now

Home
About Menai Orthodontics
- Dr Sarah Dan
- Dr Michael Counsel
Treatment
Gallery
Finance
Resource Centre
Contact Us

Suites 21 & 22, Level 1
62-70 Allison Crescent
Menai NSW 2234

Home
Resource Centre
Patient Information Form

Patient Information Form

Submitting the form below lets us get
to know you a little better.

Having this information allows us to provide you with the best personalised treatment options.

"*" indicates required fields

Patient Information

Title

Name*

First Last

Preferred Name*

Date of Birth*

Day

Month

Year

Contact No.*

Age*

Gender*

Male

Female

Other

Other*

Home Address*

Email Address (Parent / Guardian)*

Emergency Contact Details

Name*

First Last

Contact No.*

Relationship*

Account Information

Is the patient responsible for the account?*

Yes

No

If no, please provide details below:

Title

Name*

First Last

Relationship*

Contact No.*

Home Address*

Email Address*

Are there any other parties who will be financially responsible for the account?*

Yes

No

If yes, please provide details below:

Title

Name*

First Last

Relationship*

Contact No.*

Home Address*

Email Address*

Referral and Health Insurance Information

Does the patient have private health insurance?*

Yes

No

If yes, Fund name*

Has the patient had a previous orthodontic assessment?*

Yes

No

Does the patient have siblings or family members who also attend this practice (please provide their name/s)?*

How did you hear about Menai Orthodontics?*

(Dentist, family member, friend, Google search, signage, word of mouth)

Is there someone we can we thank for your referral?*

Who is your Dentist? If not currently in the care of a regular dentist, please type N/A*

Who is your GP?*

Health Information

Please indicate if any of the following is applicable to the patient

Asthma*

Yes

No

Asthma yes*

Allergy/Hypersensitivity*

Yes

No

Allergy/Hypersensitivity yes*

Epilepsy*

Yes

No

Epilepsy yes*

Diabetes*

Yes

No

Diabetes yes*

Heart/Vascular Disorder*

Yes

No

Heart/Vascular Disorder yes*

Blood Disorder/ Excessive Bleeding*

Yes

No

Blood Disorder/ Excessive Bleeding yes*

Blood Pressure*

Yes

No

Blood Pressure yes*

Cold Sores*

Yes

No

Cold Sores yes*

Hepatitis or HIV*

Yes

No

Hepatitis or HIV yes*

Rheumatic Fever*

Yes

No

Rheumatic Fever yes*

Arthritis*

Yes

No

Arthritis yes*

Liver or kidney disease*

Yes

No

Liver or kidney disease yes*

Pregnant*

Yes

No

Pregnant yes*

Requires antibiotic cover for dental procedure (Typically for known heart conditions)*

Yes

No

Requires antibiotic cover for dental procedure (Typically for known heart conditions) yes*

Tonsils/adenoids removed*

Yes

No

Tonsils/adenoids removed yes*

Ever received speech therapy*

Yes

No

Ever received speech therapy yes*

Habitual Behaviours such as finger / thumb sucking, mouth breathing, clenching / grinding*

Yes

No

Habitual Behaviours such as finger / thumb sucking, mouth breathing, clenching / grinding yes*

Other Behavioural / Medical conditions (e.g., sensory, autism, anxiety)*

Yes

No

Other Behavioural / Medical conditions (e.g., sensory, autism, anxiety) yes*

Currently on any medications*

Yes

No

Currently on any medications yes*

Is there any further medical information you would like to disclose?

Consent and Disclosure

I consent to having the following: x-rays, models and photographs published for continuing education purposes or on the web?*

Yes

No

I certify that the above medical and personal information is accurate currently. If there are future changes, I will inform this office*

I certify the above to be true

Your full name*

Relationship to patient*

Self / Patient

Parent

Guardian

Date*

Day

Month

Year

Follow us on Instagram!

Associations and Memberships

Suites 21 & 22, Level 1
62-70 Allison Crescent
Menai NSW 2234

First name(Required)

Last name(Required)

Phone number(Required)

Email address(Required)

Subscribe

Please subscribe me to the newsletter

Your message

Copyright 2024 Menai Orthodontics.

Designed and Developed by DMAOK