By submitting this form you are agreeing to our privacy policy. Terms and conditions apply
Do you have private health insurance?*
Is this your first visit to an orthodontic practice?*
Are you happy with your smile*?
Does dental treatment make you nervous?*
Do you grind your teeth or suffer from headaches?*
Have you ever had any problems with dental treatment?*
Do you suffer from gastric reflux?*
Do you suffer from snoring or sleep apnoea?*
Have you had any of the following?*
Are you currently under medical care or taking any medication?*
Are you currently taking osteoporosis medication?*
Are you allergic to any drugs, medicines or latex?*
Is there a possibility that you could be pregnant?*
Have you been hospitalised in the last 5 years?*
I consent to digital imaging to be taken as required by Knox City Orthodontics*
I consent to having my x-rays, models and photographs published for continuing dental education and internal marketing purposes.*
