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Patients Registration Form

Patients Registration FormHunt Jeong2022-05-12T14:14:34+12:00

Step 1 of 3 - PATIENT INFORMATION

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PATIENT INFORMATION

DD slash MM slash YYYY
Sex(Required)
Prefered Contact Method(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)

Full name(s) and address of person(s) responsible for accounts and pre-treatment fees.
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)
Have you been fully vaccinated for Covid19?(Required)
Please tick any conditions applicable to you:
Consent(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?

STAY IN THE LOOP

STAY IN THE LOOP

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