NEW PATIENT FORM

1. Patient Information

2. Account Holder

3. Dental / Oral History

4. Medical History

Please tick any conditions that apply:

5. Consent

Privacy Policy

The information I have given today will be held in the strictest confidence and is to the best of my knowledge true and correct. It is my responsibility to inform this office of any changes in my medical status. I authorise my health care provider to release any information, including the diagnosis and records of treatment or any examination rendered to me, to other health practitioners in relation to the orthodontic treatment.

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