New Patient at Ortho Co.?

We’re excited to meet you and support your journey to a healthy smile!

We’d love for you to complete the medical history form below before your appointment. Our friendly team will review it to ensure your first visit is comfortable and well-prepared.

Once we receive your form, our team will be in touch to confirm your appointment and provide any guidance you may need.

Thank you for choosing Ortho Co., and we look forward to welcoming you to our practice!

New Referral form

Patient details

Title:

Patient Name:

Nickname:

Surname:

Occupation:

Date of Birth:

Age:

Sex:

School & Year:

Home Address:

Suburb:

Post Code:

E-mail:

Phone

Home No:

Family Dentist:

Date of Last Check Up:

Health Fund:

Medical Practitioner:

What are your main concerns regarding your teeth or jaw?

Whom may we thank for referring you to our practice?

How did you hear about our practice?

Have you had family or friends treated in this practice?

If YES what is their name?

Is the Patient over 18?

Yes (Go to Medical History)

No (Go to Account Responsibility)

Account Responsibility

To be completed by the Patient’s Parent / Guardian / Responsible Party

Title:

First Name:

Last Name:

Relationship to Patient:

Are your contact details the same as the Patient Details noted above?

Yes (Go to Medical History)

No (Please enter only the differences below)

Home Address:

Suburb:

Postcode:

Email Address:

Mobile No:

Home No:

Child Sleep Questionnaire

Complete if Patient is 16 years and under

Consider each question over the past 6 months.

The child has difficulty in breathing during the night

Never

Occasionally (once or twice per month or less)

Sometimes

Often (3 or 5 times per week)

Always (daily)

The child gasps for breath or is unable to breathe during sleep

Never

Occasionally (once or twice per month or less)

Sometimes

Often (3 or 5 times per week)

Always (daily)

The child snores

Never

Occasionally (once or twice per month or less)

Sometimes

Often (3 or 5 times per week)

Always (daily)

Adult Sleep Questionnaire

Complete if Patient is 17 years and older

Use the following scale to choose the most appropriate number for each situation.
0 = would never doze or sleep 1= slight chance of dozing or sleeping 2 = moderate chance of dozing or sleeping 4 = high chance of dozing or sleeping

Sitting and reading

0

1

2

4

Watching TV

0

1

2

4

Sitting inactive in a public space

0

1

2

4

Being a passenger in a motor vehicle for an hour or more

0

1

2

4

Lying down in the afternoon

0

1

2

4

Sitting and talking to someone

0

1

2

4

Sitting quietly after lunch (no alcohol)

0

1

2

4

Stopped for a few minutes in traffic while driving

0

1

2

4

Dental History

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

Painful teeth?

Yes

No

If Yes,

upper right

upper left

lower right

lower left

Have any teeth been removed?

Yes

No

How Many?

Do you have or have you had any of the following habits? Finger or Thumb Sucking, Lip Biting, Nail Biting

Yes

No

Finger or Thumb sucking

Lip Biting

Nail Biting

Have you ever had an accident involving teeth, chin or jaw?

Yes

No

If yes, describe:

Have you ever had an accident involving teeth, chin or jaw?

Yes

No

If yes, describe:

Have you ever had an accident involving teeth, chin or jaw?

Yes

No

If yes, when and name of practitioner?

Interests and Activities

Hobbies:

For Children: Any information you can give me concerning your child will be appreciated. It is important that I am aware of any behavioural or schooling difficulties, and any upsetting dental experiences

YOUR HEALTH INFORMATION AND OUR PRIVACY POLICY - Our practice respects your right to privacy. More detailed information is set out in our Privacy Policy on our website: www.orthoco.com.au The information we collect will be used for the purpose of providing treatment to you. Unless you tell us you do not want to receive information from us, we will use these details to keep you updated about our services. We may also use parts of your health information for staff training, professional development and dental health research. Your personal identity will not be disclosed without your consent to do so. Your clinical information including records are may be kept in both a written form and in electronic clinical information systems. We have security measures in place to protect this information against unauthorised access, theft or other loss. We may use contracted external providers to assist us with this data storage, these providers are based in Australia. You may inspect or request copies of your treatment records at any time, if you want copies, a fee may apply. It is important that the information we hold about you remains accurate. Please advise our staff if your contact or medical details ever change. If you have any queries or concerns about our handling of your health information, please do not hesitate to raise these concerns with our practice.

CONSENT TO DENTAL PHOTOGRAPHY- I, authorize Ortho Co., to take photographs, and/or videos of my face, jaws and teeth, before, during and after treatment. I consent to allow the photographs to be used for the following: dental records, education and research including lectures, professional publications, marketing material, including websites and printed materials, social media, and patient education. I further understand that if the photographs and/or videos are used, Ortho Co. will make all reasonable effort to safeguard your privacy and to conceal your identity if requested. I do not expect compensation, financial or otherwise, for the use of these photographs and relinquish any and all rights to the any images of me obtained by any photographic or digital means by Ortho Co.

Tick here if you do not want your full-face photos used for any of the above purposes.

Signature of Responsible Party:

Date:

If you are human, leave this field blank.

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