Personal medical information

Kindly fill in the medical history form below

Fields marked * are required.

New Patient ADULT Form

Patient’s First Name*

Patient’s Surname*

Patient’s Preferred Name*

Date of birth*

Gender* Male Female Unspecified

Patient’s Last Dental Appointment* 0-6mths 6-12mths over 12mths

Patient’s Phone*

Occupation*

Patient’s Address*

Postal Address*

Financially Responsible Person's Name*

Financially Responsible Person's Email*

Financially Responsible Person's Address*

Name of Health Fund*

General Dentist’s name*

Family Physician’s name*

Reason for seeking orthodontic treatment*

Has the dentist provided a written referral?* Yes No

If Yes, please give details*

Did either parent have orthodontic treatment?* Yes No

If Yes, please give details*

Have you lost all your baby teeth? No Yes

If No, please give details*

Have you had any of the following, if YES – please give details

Previous orthodontic treatment/consultation* Yes No

If Yes, please give details*

Any injuries to teeth* Yes No

If Yes, please give details

Extractions* Yes No

If Yes, please give details

Impacted teeth* Yes No

If Yes, please give details

Do you have (or have had) any of the following –

Are you currently -

Do you require antibiotic cover for dental treatment?* Yes No

If Yes, please give details

Is there any other information you feel is relevant to your dental history / appointment?*

How did you hear about us?*

Why did you choose Torque Orthodontics?*

Date*

Privacy consent

The Privacy Act of December 21, 2001 states that we must have consent to collect personal information about you. Please read this information carefully and sign, where indicated, below.

This dental practice collects information from you for the primary purpose of providing quality dental care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your dental care needs. This means we will use the information you provide in the following ways:

Administrative purposes in running our dental Practice
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your dental care, including treating doctors, specialists, and other para medical personnel including educators, community health and hospital staff, outside this dental practice. This may occur through referral to other doctors, or for medical tests including imaging / radiology and in the reports returned to us following the referrals. This information, including photographs and x-rays may be sent by email and/or other digital means.
Disclosure to other orthodontists in the practice, locums and by Registrars attached to the practice for the purpose of patient care and teaching. Please let us know if you do not want your records assessed for these purposes, and we will note your record accordingly.
Disclosure for research and quality assurance activities to improve individual and community health care and practice management. You will be informed when such activities are being conducted and given the opportunity to “opt out” of any involvement.

** I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information.
** I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.
** I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.
** I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.
** I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of. This consent is valid indefinitely.

Please sign here: