Take the step to your future smile "*" indicates required fields Personal DetailsPatients Name* Email* Patient DOB* DD slash MM slash YYYY Phone*Postcode* Address* Gender* Male Female Non Binary Responsible party detailsMother’s InformationMother's Name Address Email Phone (Home)Phone (Work)Phone (Mobile)Father’s InformationFather's Name Address Email Phone (Home)Phone (Work)Phone (Mobile)Guardian InformationGuardian Name Address Email Phone (Home)Phone (Work)Phone (Mobile)How did you hear about us?Referrals Friends or Family Dentist, Dental Practice, Oral Health Therapist Google Facebook Instagram Other Referrer Name – If applicable If we were recommended to you, please let us know by whom? Please let us know how you found us – If applicableMedical HistoryDoes the patient have a health problem?* Yes No Patient health problem details*If yes please list Is there a history of serious illness, accident or operation?* Yes No Is the patient under a doctor's care for any problem at this time details*If yes please list Is the patient under a doctor's care for any problem at this time?* Yes No Patient under doctor's care details*If yes please list Is the patient taking any medication?* Yes No Patient current medication details*If yes please list Does the patient have any allergies or drug sensitivities?* Yes No Patient allergy or drug sensitivity details*If yes please list Dental HistoryHas the patient had an orthodontic consultation previously?* Yes No Has the patient had any previous orthodontic treatment?* Yes No Has the patient had any injury to the teeth? (This includes both baby & permanent teeth)* Yes No Has the patient had any injury to the face, jaw or gums?* Yes No Has the patient had any cysts or tumours of the jaw or gums?* Yes No Have you been informed of any missing or extra permanent teeth?* Yes No Does the patient suck fingers or thumbs, or have a similar habit?* Yes No Date of last dental examination DD slash MM slash YYYY Name of usual Dentist or Dental Practice Please be advised by signing this document you agree that any accounts remaining unpaid without being discussed and approved by Dr Donna Lim or our Financial Coordinator may be sent to debt collection where further action will be taken to collect the amount owed which may include but is not limited to further costs being added.Do you agree to do a blood test if required?* Yes No Wish to discuss with the dentist Although rare, accidental injury to staff can occur during handling of used instruments. If this happens during the course of your treatment our practice requires both the patient and staff member to undertake confidential blood tests.Full name Date MM slash DD slash YYYY SignaturePhoneThis field is for validation purposes and should be left unchanged.