We will be closed from 22 December and will reopen on 19 January, 2026. For emergencies, please call 09 627 3555 and follow the voice message for our emergency contact details. Wishing you and your family a safe and Merry Christmas and a Happy New Year!

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Patient information
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Child medical information

Child Medical history form

Please fill in all fields marked with *

Patient details

Name*

DOB*

Address*

Email*

Phone (Home)*

Phone (Work)*

Phone (Mobile)*

Responsible party details

Mother's Information

Name

DOB

Address

Email

Phone (Home)

Phone (Work)

Phone (Mobile)

Living with Mother

Yes

No

Father's Information

Name

DOB

Address

Email

Phone (Home)

Phone (Work)

Phone (Mobile)

Living with Father

Yes

No

Self/Guardian Information

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?*

Medical History

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*

Dental History

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

Please sign here (Signature of parent/guardian if patient is under 18 years old)

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