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Call us (07) 5447 5307
Book a Complimentary Consultation

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Adult Medical History Form

To ensure we have all the information we need for your first visit, please fill out the appropriate health history form below.

"*" indicates required fields

Fields marked * are required.

Patient Details:

Title* Mr Ms Mrs Miss Mstr

Gender* Male Female Prefer not to answer Not listed

First name*

Surname*

DOB*

Home Address*

Postcode*

Postal Address*

Postcode*

Mobile*

Home Phone

Work Phone

Email*

Referred to the practice*

Health Fund*

1st Responsible Party Details

Are you responsible for billing of treatment?* Yes No A percentage I am responsible for my own fees.

Title Mr Ms Mrs Miss

Name

DOB

Address

Town

State

Postcode

Relationship to patient

Marital Status

Spouse name

Consent to receive SMS appointment reminders* Yes No

Consent to receive emails from clinic* Yes No

I hereby provide consent for the disclosure and sharing of my contact details with other relevant billing parties* Yes No

2nd Responsible Party Details

Are you responsible for billing of treatment? Yes No A percentage

Title Mr Ms Mrs Miss

Name

DOB

Address

Town

State

Postcode

Relationship to patient

Marital Status

Spouse name

Consent to receive SMS appointment reminders Yes No

Consent to receive emails from clinic Yes No

I hereby provide consent for the disclosure and sharing of my contact details with other relevant billing parties Yes No

Health History

Name of Dentist*

How long since your last Dental check-up?*

Are you currently receiving Medical Treatment?* Yes No

If yes, please details

Are you taking any Medication, Pills or Drugs?* Yes No

If yes, please details

Have you ever had Bisphosphonate Treatment?* Yes No

If yes, please details

Are you allergic to anything?* Yes No

If yes, please details

Do you suffer from mouth ulcers?* Yes No

If yes, please details

Do you suffer from anxiety/depression?* Yes No

If yes, please details

Any behaviour disorders we should be aware of?

Do you smoke?* Yes No

Women, If Pregnant what is your approximate due date?

Have you ever had any of the following?*

Rheumatic Fever

Hepatitis

Diabetes

Tuberculosis

Epilepsy

Artificial Heart Valves and Joint

Deep Ray (Cancer) Therapy to Head/Neck

Anaemia or Blood Disease

Asthma, Bronchitis or Sinusitis

Blood Pressure

Hyperthyroidism

Glaucoma

Nervous Disorder

Ear Trouble

Allergies

How did you hear about our practice?*

Referring dentist

Word of mouth

Advertising

Radio

Cinema

Newspaper

Family/Friend

Dentist

Other

If Family/Friend, please specify their full name

If Dentist, please specify their clinic name

If Other, please specify

If you have a referral for orthodontic treatment, please upload it here Accepted file types: jpg, gif, png, pdf (upto 8 files only).

Privacy Consent

I give consent to Junction Orthodontics collecting, sharing and using my/my child's personal and health information as described above.

collect personal and health information about you, from you directly and from other sources such as other health practitioners involved in your relevant care and treatment, to provide you with Orthodontic services and treatment Yes No

Using my information and images for research and educational purposes Yes No

Using my personal information and certain images for marketing and promotional purposes (if I consent to this, my image and/or name would be publicly available): Yes No

Date*

Please sign here:

Junction Orthodontics

1/34 Sunshine Beach Rd,
Noosa Heads, QLD 4567

(07) 5447 5307

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Book a Complimentary Consultation

Your first visit is FREE!

First Name *

Last Name *

Email *

Phone *

Please be advised: To reschedule any existing appointments, kindly contact: (07) 5447 5307.