Name*

DOB*

Address*

Email*

Phone (Home)*

Phone (Work)*

Phone (Mobile)*

Name

DOB

Address

Email

Phone (Home)

Phone (Work)

Phone (Mobile)

Living with Mother

Yes

No

Name

DOB

Address

Email

Phone (Home)

Phone (Work)

Phone (Mobile)

Living with Father

Yes

No

Name

DOB

Address

Email

Phone (Home)

Phone (Work)

Phone (Mobile)

Living with Guardian

Yes

No

Person responsible for the payment of accounts?*

Whom may we thank for referring you to our practice?

What is your school or place of work?*

Who is your regular Dentist/Dental Nurse?*

Who is your regular doctor?*

Are you being treated for anything now and if so for what?*

Do you have any allergies?*

Yes

No

If yes, please list*

Do you have or ever had any of the following?*

Heart Problems

Rheumatic Fever

Jaundice or Hepatitis

Diabetes

Epilepsy

Asthma

Bleeding Problems

Other

Are you taking any medications/herbal supplements?*

Yes

No

If yes, please list*

Has the patient had an orthodontic consultation previously? *

Yes

No

Has the patient had any previous orthodontic treatment? *

Yes

No

Has the patient had any injury to the teeth? (this includes both baby & permanent teeth) *

Yes

No

Has the patient had any injury to the face, jaw or gums? *

Yes

No

Has the patient had any cysts or tumours of the jaws or gums? *

Yes

No

Have you been informed of any missing or extra permanent teeth?*

Yes

No

Does the patient suck fingers or thumb, or have a similar habit*

Yes

No

Date of last dental examination

Reason for seeking orthodontic treatment *

Date

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Child Medical history form

Patient details

Responsible party details

Mother's Information

Father's Information

Self/Guardian Information

Medical History

Dental History

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Child Medical history form

Patient details

Responsible party details

Mother's Information

Father's Information

Self/Guardian Information

Medical History

Dental History

Book Your Free Consultation

Instagram Posts Get social with Auckland Orthodontics

Find Us

Book Your
Free Consultation