Welcome Form Welcome To Our Practice Please fill in the form below for our team to review Welcome Form Patient Details Surname * First Name * (as it appears on your Medicare card) Preferred Name Date of birth * Age Anatomical Gender * Email * required for statements, receipts and notifications (no marketing information) Name of School/Study (if appropriate) Home Address * Post Code * Postal Address (if differs from home address) Post Code Patient's Phone * Alternative contact name Alternative contact mobile Responsible Account Holder (if patient under 18) Responsible Account Holder Please tick if same as above (a responsible party must be an Australian citizen, employed, 18 years of age or older and not subject to bankruptcy or any debt agreements. Written consent is required if a third party is responsible for accounts.) Full name Account Address Post Code Email Phone Alternative Contact & Relationship Alternative Contact Mobile Dentist (Where you go for check up & cleans) Clinic Name/ Suburb Dr/ Hygienist Name Do you have Private Health insurance? * Yes No Name of Private Health Fund Have we treated any other member of the family? * Yes No If yes, Full Name Medical History Asthma Lung Problems Blood Pressure Heart Conditions Bleeding problems HIV/AIDS Diabetes Autism Aspergers Sensory issues Bisphosphonate treatment Anxiety/ Anxious at the dentist Hepatitis Epilepsy Radiation/ Chemotherapy Currently taking any medication? * Yes No Please state medication Any known allergies? * Yes No Please state allergies Any other illness? * Yes No Please state other illness Who can we thank for recommending our Practice? Referral * Dental Practice Google Family/Friend Instagram Facebook Website Other Please write name of your friend/family member Please state Other referral Photographic Consent & Privacy Policy *Social media requests will be via a seperate consent form As part of your treatment, photographic images will be required. Any images will be treated with the same confidentiality as other personal information collected by Gentle Touch Orthodontics. Our Privacy Policy is available on our website. Our server is not cloud based for privacy. For the privacy and safety of our staff and patients, audio and video recording on your personal device is not permitted in our practice. Please ask permission prior to taking photos or recording. Patient or Parent/Guardian signature (if child is a minor) * signature keyboard Clear Submit If you are human, leave this field blank. Get The Smile You Want With Our Gentle Touch. Please select a valid form Get Started
