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Embrace Orthodontics LogoEmbrace Orthodontics Logo
  • EMBRACE TEAM
    • INFO
    • EMBRACE TEAM
  • OUR SERVICES
  • NEW PATIENTS
    • NEW PATIENTS
    • PATIENT REGISTRATION
    • BEFORE & AFTER GALLERY
  • OUR PATIENTS
  • CONTACT US
Embrace Orthodontics LogoEmbrace Orthodontics Logo
  • EMBRACE TEAM
    • INFO
    • EMBRACE TEAM
  • OUR SERVICES
  • NEW PATIENTS
    • NEW PATIENTS
    • PATIENT REGISTRATION
    • BEFORE & AFTER GALLERY
  • OUR PATIENTS
  • CONTACT US
PATIENTkmongwd2021-11-30T21:54:13+13:00

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PATIENT INFORMATION

Have you made an appointment with us?(Required)
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

DD slash MM slash YYYY
Sex(Required)
Name Age Actions
   
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There are no Siblings.

Maximum number of siblings reached.

BILLING INFORMATION (IF YOU ARE UNDER 18 YEARS OF AGE)

Name Work Work Phone Mobile Actions
       
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There are no Guardians/Parents.

Maximum number of guardians/parents reached.

EMERGENCY CONTACT (SOMEONE OTHER THAN THE BILLING PARTY)

REFERRER AND CONTENT

How did you hear or find out about us?

CONSENT

I consent to the use of my treatment records and photos for educational or communication purposes(Required)

MEDICAL HISTORY

Are you currently under any medical treatment?
Are you taking any medications including herbal?
Have you ever had any serious illness and/or operations in hospital?
Have you had any allergic reactions to drugs or medications?
Do you have any allergies eg. nickel or latex?
Are you pregnant? (female only)
Please tick any conditions applicable to you:
Have you been fully vaccinated for Covid19?(Required)
Consent 2(Required)
(Required)

Treatment Attitudes and Expectations

CHECK ALL STATEMENTS BELOW THAT APPLY TO THE PATIENT:
The Teeth
The Bite
Dental Problems

The Dentist

The Orthodontist

The Orthodontist

Expectations

What I Expect from Orthodontic Treatment
How Soon Would You Like to Get Started?

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STAY IN THE LOOP

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  • BRACES
  • INVISALIGN ALIGNERS
  • FUNCTIONAL APPLIANCES
  • ADULT ORTHODONTICS
  • SURGICAL ORTHODONTICS
  • HOMECARE
  • EMERGENCY CARE
  • RETAINERS
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