(07) 4951 4100
Free Invisalign consultation
Torque Orthodontics / Patient info / New patient forms / New Patient - Adult form

Personal medical information

Kindly fill in form for your Medical history or download our form below.

Download form

Fields marked * are required.

PERSONAL & MEDICAL HISTORY - Adult

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Do you suffer from (or have you ever had) any of the following?

Rheumatic fever

Heart disease/Heart Murmur

Stroke

High/Low blood pressure

Diabetes

Fits/ Epilepsy/Fainting/Dizziness

Asthma- Mild, Moderate, Severe

Rheumatism

HIV/AIDS

Hepatitis

Any blood disorder

Joint problems /replacement

Disorder of the stomach, bowel or digestive system

Cancer/Tumors (Benign/ Malignant)

Osteoporosis

Yes No Yes No Yes No Yes No

Please note that we only treat you according to the information you have provided for us.

Book a consultation

  • Meet our specialist orthodontist
  • Digital photos and x-rays
  • Get a treatment plan and costs

Fields marked * are required.

 

By clicking submit you are agreeing to our privacy policy