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Medical forms

Telling us your medical history will help us in treating your smile. Please fill out the forms below.

Fields marked * are required.

Patient Details

Gender*

Male Female Prefer not to answer Not listed

Preferred Pronoun*

He She They Prefer not to answer Not listed

Patient's First Name*

Patient's Last Name*

Date of Birth*

Home Address*

Suburb*

Postcode*

Phone No (H)*

Phone No (W)*

Phone No (M)*

Email Address*

Patients School / University

If patient is a minor, please give parent(s) or Guardian’s names:

Patient lives with: Parent(s) / Mother / Father / Self /Other*

Family Dentist

Who referred you to our practice?

Medicare number

Reference

Are you covered for Orthodontic Treatment by private health insurance?*

Yes No

If so, name of insurer

Responsible Party Information (The Person who is responsible for paying for your treatment)

The payment plans we offer are based on the information you provide below and are designed to help you.
If you do not wish to complete this section below, then we shall be very limited in the financial arrangements we can offer you.

Or, please provide details if responsible party is different to patient:

First Responsible Party Details

Responsible Party First Name

Responsible Party Last Name

Date of Birth

Relationship

Home Address

Postcode

Phone No (H)

Phone No (W)

Phone No (M)

Employer/s

Occupation/s

Second Responsible Party Details

Responsible Party First Name

Responsible Party Last Name

Date of Birth

Relationship

Home Address

Postcode

Phone No (H)

Phone No (W)

Phone No (M)

Employer/s

Occupation/s

Other than the responsible parties listed above, are there any other individuals or legal guardianship arrangements, in place that require specific consent for the patient to elect treatment and/or who need to be involved in the ongoing management of the orthodontic treatment?*

Yes (Our team will require a supplementary form to be completed) No

Emergency Information

Contact Person

Relationship

Phone No (H)

Phone No (W)

Phone No (M)

General Information

Has the patient had an orthodontic consultation before?*

Yes No

If “yes” with whom

Has the patient ever had orthodontic treatment?*

Yes No

If “yes” with whom and what was the treatment?

Any medical/behavioural conditions, allergies or illnesses?*

Yes No

If “yes”, please give details

Have you had any problems with dental treatment?*

Yes No

If “yes”, please give details

Have any other family members had orthodontic treatment with us?*

Yes No

If “yes”, what is the patient’s name?

Are you taking any prescribed medication/s?*

Yes No

If “yes”, please note medications

I understand that the above information will be kept strictly confidential.

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CONTACT US

Ready to transform your smile? Contact us!

Our team can’t wait to put a smile on your face.

Warrnambool Orthodontic Hub

171a Liebig St,
Warrnambool VIC 3280

admin@wohub.com.au

Opening Hours

Monday 8:30am – 5:00pm
Tuesday 8:30am – 5:00pm
* Wednesday 8:30am – 1:00pm
Thursday 8:30am – 5:00pm
Friday 8:30am – 5:00pm
Saturday Closed
Sunday Closed

* Enquiries only

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