Patient Form

Welcome to Gippsland Orthodontics. Dr Adam Wallace and the team look forward to seeing you for your consultation in the near future. We kindly request that the below Patient Information form is completed prior to your initial consultation.

If there are any questions regarding this form do not hesitate to contact us here.

Patient information

Person responsible for accounts:

Do you have Private Health Insurance?

For child/adolescent patients only

Parents are

Patient Medical and Dental History

Please (x) any of these conditions that the patient has had:

If yes to any of the above please give details

What medication is the patient taking?

What dental treatment has the patient had?

Were there any difficulties with treatment?

Have any teeth been extracted?

Have there been any accidents involving the teeth or jaws?

Has the patient had orthodontic treatment before?

Is the patient now

Women, are you pregnant?

Does the patient smoke?

Does the patient drink alcohol regularly?

I would like to discuss the above questions in private