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(03) 218 9970
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EMBRACE TEAM
INFO
EMBRACE TEAM
OUR SERVICES
NEW PATIENTS
NEW PATIENTS
PATIENT REGISTRATION
BEFORE & AFTER GALLERY
OUR PATIENTS
CONTACT US
Toggle Navigation
EMBRACE TEAM
INFO
EMBRACE TEAM
OUR SERVICES
NEW PATIENTS
NEW PATIENTS
PATIENT REGISTRATION
BEFORE & AFTER GALLERY
OUR PATIENTS
CONTACT US
PATIENT
kmongwd
2021-11-30T21:54:13+13:00
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PATIENT INFORMATION
Have you made an appointment with us?
(Required)
Yes
No
We would appreciate it if you could make an appointment by phone (
03 218 9970
) or email (
reception@embraceortho.co.nz
) before filling out the registration form.
PATIENT INFORMATION
First Name
(Required)
Surname
(Required)
Preferred Name
Email
(Required)
Date of Birth
(Required)
DD slash MM slash YYYY
Sex
(Required)
Male
Female
Rather not say
Street Address
(Required)
Address Line Two
Suburb
(Required)
City
(Required)
Post Code
(Required)
Phone
(Required)
Mobile
(Required)
If not, how would you prefer to be contacted?
Occupation (if applicable)
School (if applicable)
SIBLINGS
Name
Age
Actions
Edit
Delete
There are no
Siblings.
Add Sibling
Maximum number of siblings reached.
BILLING INFORMATION (IF YOU ARE UNDER 18 YEARS OF AGE)
GUARDIAN/PARENT
Name
Work
Work Phone
Mobile
Actions
Edit
Delete
There are no
Guardians/Parents.
Add Guardian/Parent
Maximum number of guardians/parents reached.
EMERGENCY CONTACT (SOMEONE OTHER THAN THE BILLING PARTY)
Name
(Required)
Relationship
(Required)
Phone
(Required)
REFERRER AND CONTENT
How did you hear or find out about us?
Website
Facebook
Google
Friends / Family
Dental practitioner
Word of mouth
Yellow pages
Other
Who referred you?
Family Dentist
CONSENT
I consent to the use of my treatment records and photos for educational or communication purposes
(Required)
YES
NO
MEDICAL HISTORY
Family Doctor
Are you currently under any medical treatment?
Yes
No
Are you taking any medications including herbal?
Yes
No
Have you ever had any serious illness and/or operations in hospital?
Yes
No
Have you had any allergic reactions to drugs or medications?
Yes
No
Do you have any allergies eg. nickel or latex?
Yes
No
Are you pregnant? (female only)
Yes
No
Please tick any conditions applicable to you:
AIDS/HIV
Anaemia
Arthritis/Rheumatism
ADH
Asthma/Hayfever
Bleeding problems
Blood disease
Bone disorder
Cancer
Diabetes
Emotional problems
Epilepsy
Frequent headaches
Frequent colds/flu
Heart problems
Hepatitis
Herpes (Cold sores)
High/low Blood pressure
Kidney disease
Liver disease
Osteoporosis
Pneumonia/Bronchitis
Radiation treatment
Sinus problems
Stroke
Thyroid problems
Tonsils/adenoids
Tuberculosis
Other
Have you been fully vaccinated for Covid19?
(Required)
Yes
No
Please let us know what medical treatment you are under.
(Required)
Please let us know what medications you take including herbal.
(Required)
Please let us know what serious illness and/or operations you had or have in hospital.
(Required)
Please let us know what allergic reactions to drugs or medications you had or have.
(Required)
Consent 2
(Required)
I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status.
(Required)
Treatment Attitudes and Expectations
CHECK ALL STATEMENTS BELOW THAT APPLY TO THE PATIENT:
The Teeth
There are spaces between the teeth that I do not like.
The teeth are crooked and overlapping.
The teeth stick out too far.
The mouth seems too small, not enough room for the teeth.
The teeth are coming in the wrong places.
Not aware of any problems.
The Bite
The bite is comfortable and I can eat what I want with no difficulties.
I feel there is a problem with the bite or I have been told there is a problem.
I have frequent or chronic pain in my jaws, face or head.
My jaws click, pop, or lock when I open my mouth.
I have or have had difficulty in opening and/or closing my jaws.
Dental Problems
I have no dental problems that I am aware of other than misaligned teeth.
I have had some trauma to my baby or adult teeth.
I have been advised of some missing teeth.
I currently suck my thumb or finger.
Other
Other Dental Problem Details:
The Dentist
I visit the dentist regularly, at least every ________ months.
It has been ______ years since I had my teeth checked by the dentist.
The Orthodontist
The Orthodontist
This is my first experience with an orthodontist.
I have worn braces before ________ year(s).
I have seen another orthodontist and I would like a second opinion. (Please enter your current Dr. name)
Expectations
What I Expect from Orthodontic Treatment
I want all the teeth straightened and the bite corrected if possible.
I want the upper and lower teeth straightened and aligned.
I only want the upper teeth straightened and aligned.
I only want to find out if any treatment is needed.
How Soon Would You Like to Get Started?
I would like to get started as soon as possible if it is determined that treatment is indicated.
I want to meet with the orthodontist to discuss the results of the diagnosis before making a decision.
I want to discuss the findings with my spouse before making a decision to start treatment.
I want to delay treatment as long as possible.
Do you have any questions or information for us?
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