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Dentist Referrals

Northcote Burwood

Dentist Referrals
Northcote
Burwood
1300 367 678

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- Northcote
- Burwood

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Patient Medical History

Personal details

Preferred Location*

Northcote Burwood

Title*

Mr Mrs Miss M/s Dr

First name*

Middle name

Last name*

Common name

Sex assigned at birth*

For medical and orthodontic purposes, please tell us the sex you were assigned at birth.

Male Female Intersex Prefer not to say Unsure / not known

This question is about the sex recorded or assigned at birth, rather than your current gender identity. We ask this because biological factors can be relevant to your medical and orthodontic care.

Gender identity

How would you describe your gender?

Male Female Non-binary Prefer not to say

Other gender identity

Preferred pronouns

We will use your preferred name and pronouns and respect your gender identity throughout your care.

Date of birth*

Home Address*

Post Code*

Email*

Mobile phone*

Home phone

Occupation

Employment Status

Emergency Contact*

Title*

Mr Mrs Ms Miss Dr

Surname*

Given Names*

Mobile Ph*

Relationship to patient*

Are you an Australian Citizen or Permanent Resident*

Australian Citizen Permanent Resident Other

If you would like to speak a language other than English (and what language it is)

Are you covered by dental insurance?*

Yes No

Fund Name*

Medical Information

Family Doctor*

Address of Doctor

Post Code*

Patient's dentist*

Date last seen by dentist*

Patient's Medical and Dental History

Please check if you ever had any of the following*

Asthma

Anemia

HIV Aids

Hepatitis

Epilepsy

Rheumatic Fever

Diabetes

Psychiatric Care

Head or Face Injury

Hormonal Disorder

Bone Disorder

Emotional Disorder

Bleeding Disorder

Blood Disease

Hearing disorder

Heart Disease

What medications are you currently taking?*

Are you pregnant?* Yes No

Do you smoke?* Yes No

Do you have any allergies?* Yes No

If yes, what are the allergies?

Are there any other medical problems we should be aware of?*

Pain or clicking in the jaw joints?* Yes No

Chewing and swallowing difficulty?* Yes No

Grind your teeth?* Yes No

Do you have any habit such as tongue thrust/ thumb sucking/nail or object biting?* Yes No

Have your teeth ever been injured due to an accident or having received a serious blow?* Yes No

If yes, when?

What kind of breather are you?* Nose breather Mouth breather Mixed nose and mouth breather

When did you have your last Dental Check - Up?

Do you have any outstanding general dental work to be completed?

Why have you come to see us?

I would like to have a beautiful smile.

I have been to see a dentist and would like a second opinion.

I have been to see another specialist orthodontist and would like a second opinion.

Other

Have you had previous orthodontic consultation/treatment?

Person responsible for paying your accounts*

Myself Parent Guardian Other

Title* Mr Mrs Ms

First name*

Surname*

Address*

Post Code*

Occupation

Employment Status

Is responsible party Australian Citizen or Permanent Resident* Australian Citizen Permanent Resident Other

Complete this section if you are financially responsible for the patient.

Title Mr Mrs Ms

Surname

Given Names

Address

Post Code

Home phone

Work phone

Mobile phone

Email

Whom may we thank you for referring you?

My Dentist(Name and practice)

Family / Friend (Name)

School newsletter(Name)

Newspaper advertisement(Name)

Past or existing patient treated by Modern Orthodontics(Name)

Other

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Northcote
Burwood

Modern Orthodontics Northcote

18 Robbs Parade,
Northcote, VIC 3070

info@modernorthodontics.com.au

Opening Hours

Monday: 9am to 5pm
Tuesday: 8:30am to 6pm
Wednesday: 8:30am to 5:30pm
Thursday: 9am to 6pm
Friday: 9am to 6pm
Saturday: 8:30am to 4:30pm / Closed alternating weeks
Sunday: Closed

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Modern Orthodontics Burwood

1 Leonard Street,
Burwood, VIC 3125

info@modernorthodontics.com.au

Opening Hours

Monday: 9am to 5pm
Tuesday: 8:30am to 5:30pm
Wednesday: 8:30am to 6pm
Thursday: 9am to 5:30pm
Friday: 8:30am to 6pm
Saturday: Closed
Sunday: Closed

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