Knox City Orthodontics
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New Patient Form

Patient details

Person responsible for this account*

Do you have private health insurance?*

Dental History

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?*

Medical History

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?*

How did you find out about Knox City Orthodontics?*

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.*