New Patient Under 18

Latest Media

Age Groups

Kids Orthodontics

Treatment for kids under 11

Teen Orthodontics

Confident smiles for teens

Adult Orthodontics

Straightening solutions for adults

Treatments

Braces

Traditional braces for alignment

Clear Aligners

Nearly invisible solutions

Retainers

Keep your smile aligned

Other Services

Collaboration with specialists

The Practice

Your First Visit

What to expect

Pricing & Finance

Flexible payment options

Patient Resources

Helpful guides and information

In the Community

Invested in the Community

1Patient Details

2Guardian Details

3Account Information

4Medical History

5Dental History

6Disclaimer

This field is for validation purposes and should be left unchanged.

Patient Details

Patient First Name*

Patient Last Name*

Patient Date of Birth*

Patient Gender*

Patient School (Optional)

Patient Address*

Address Address Line 2 City ZIP / Postal Code

Guardian 1 Details

Guardian 1 Relationship to Patient*

Mother

Father

Other (Please Specify)

Guardian 1 Relationship to Patient*

Guardian 1 First Name*

Guardian 1 Last Name*

Guardian 1 Phone Number*

Guardian 1 Email Address*

Guardian 1 Address*

Same as Patient

Other

Guardian 1 Address*

Address Address Line 2 City ZIP / Postal Code

Would you like to enter details for a second Guardian?*

Yes

Guardian 2 Details

Guardian 2 Relationship to Patient*

Mother

Father

Other (Please Specify)

Guardian 2 Relationship to Patient*

Guardian 2 First Name*

Guardian 2 Last Name*

Guardian 2 Phone Number*

Guardian 2 Email Address*

Guardian 2 Address*

Same as Patient

Other

Guardian 2 Address*

Address Address Line 2 City ZIP / Postal Code

Account Information

Person Responsible for Patient Fees*

Guardian 1

Guardian 2

Other (Please Specify)

Account Holder Name*

Account Holder Relationship to Patient*

Account Holder Phone*

Account Holder Email Address*

Medical History

Doctor's Name*

Has the patient had or does the patient have any of the following?

Please select the boxes that relate to the patient.

Rheumatic Fever

High Blood Pressure

Blood Vessel Disease

AIDS / HIV Infection

Kidney Trouble / Diabetes

Ulcers / Cold Sores / Herpes (any type)

Asthma

Mental Health Problems

Ear Disorder

Allergies

Heart Murmur

Heart Attack / Stroke

Blood Disorder / Anaemia

Hepatitis A, B or C

Gastric Problems

Persistent Head Aches / Migraine / Neck Pains

Nerve or Brain Disease

Bone Disorders

Sinus Infection

Cancer

Has the patient had any prosthetic surgery?*

ie. heart valves or hip replacements.

Yes

Has the patient presently, or has the patient ever been, under the care of a psychiatrist or psychologist?*

If yes, please describe.

Yes

Please describe the patient's care under a psychiatrist or psychologist*

Is the patient allergic to any medications (e.g. aspirin, penicillin, etc)?*

If yes, what?

Yes

Please describe the patient's allergies*

Has the patient ever had a general anaesthetic?*

If yes, when?

Yes

Please note when the patient had general anaesthetic*

Is the patient under a doctor’s care at present?*

If yes, please describe.

Yes

Please describe the care the patient is under with their doctor*

Is the patient currently taking any medication?*

If yes, please describe.

Yes

Please describe any medications the patient is currently taking*

Has the patient had their tonsils removed?*

If so, when?

Yes

Please note when the patient had their tonsils removed*

Please note any other significant information about the patient's medical history, including drug dependence.

Dental History

Dentist Name

Date of Last Check Up

Does the patient experience painful teeth?*

Please select the boxes that relate to you.

Yes

Upper right

Upper left

Lower right

Lower left

Has the patient experienced any of the following?*

Please select the boxes that relate to you.

Wisdom teeth removed

Injuries in the head and neck area

Surgery in the head and neck area

Noticed soreness, tightness or pain in the muscles around the jaws/ face

Treatment for periodontal disease (gum disease)

Fallen and bumped your chin, or received a blow to the jaws

Clenching or grinding of your teeth

Pain when chewing

Does the patient hear clicking (popping) or grating sounds in the jaw joints?*

Clicking

Grating

Both

Describe Clicking

Clicking

Left

Right

Both

Clicking

Began Gradually

Began Suddenly

Clicking Since When?

Clicking During What Activity?

Describe Grating

Grating

Left

Right

Both

Grating

Began Gradually

Began Suddenly

Grating Since When?

Grating During What Activity?

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Dental History Continue

Was there some specific event that started the joint sounds?*

If yes, please describe.

Yes

Please describe the event that started the joint sound*

Has the patient ever experienced difficulty in opening or closing their jaws, or “locking” of the jaws open or closed?*

If yes, please describe.

Yes

Please describe the difficulty in opening or closing their jaws, or “locking” of the jaws open or closed*

Has the patient had pain in their jaw joints?*

Yes

Describe Jaw Joint Pain

Jaw Joint Pain

Left

Right

Both

Jaw Joint Pain

Began Gradually

Began Suddenly

Jaw Joint Pain Since When?

Jaw Joint Pain During What Activity?

What Increase the Pain?

What Decreases the Pain?

This field is hidden when viewing the form

Dental History Continue

Does the patient have or has the patient had any of the following habits?*

Finger / Thumb sucking

Lip biting

Nail Biting

Has any other member of your family been a patient of this practice?*

If yes, please provide their name.

Yes

Family Member Name*

Have you had previous orthodontic treatment?*

If yes, please provide details.

Yes

When Did You Have Orthodontic Treatment?

Name of Orthodontist

Have you ever been treated for this problem before?*

If yes, please describe the diagnosis and treatment.

Yes

Diagnosis and Treatment*

Please describe in your own words why you sought this consultation*

Disclaimer

Consent*

I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there are any later changes to my clinical history, I recognise that it is my responsibility to inform this office. I also give my permission for a clinical examination and agree to take responsibility for associated fees.

I agree.

Signature*

In Person Doctor Consultation with Dr.Anél

Free Consultation with Our Treatment Coordinator

Retainer Consultation for Replacements & Repairs

New Patient Under 18 in Manly

Patient Details

Guardian 1 Details

Guardian 2 Details

Account Information

Medical History

Dental History

Describe Clicking

Describe Grating

Dental History Continue

Describe Jaw Joint Pain

Dental History Continue

Disclaimer

manlyorthodontics

In Person Doctor Consultation with Dr.Anél

Free Consultation with Our Treatment Coordinator

Retainer Consultation for Replacements & Repairs

New Patient Under 18 in Manly

Patient Details

Guardian 1 Details

Guardian 2 Details

Account Information

Medical History

Dental History

Describe Clicking

Describe Grating

Dental History Continue

Describe Jaw Joint Pain

Dental History Continue

Disclaimer

manlyorthodontics

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