PATIENT

Step 1 of 4 - CHECK APPOINTMENT

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PATIENT INFORMATION

Have you made an appointment with us?(Required)

Yes

Appointment Date(Required)

DD slash MM slash YYYY

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.

First Name(Required)

Surname(Required)

Preferred Name

Salutation

Email(Required)

Mobile(Required)

Landline

Date of Birth(Required)

DD slash MM slash YYYY

Sex(Required)

Male

Female

Gender Neutral

Gender Neutral Type(Required)

Street Address(Required)

Address Line 2

City / Region(Required)

Post Code(Required)

Occupation (if applicable)

School (if applicable)

Parent/Guardian

All patients under the age of 18 are required to enter at least one parent/guardian.

Name	Work	Mobile	Email	Address	Is this parent/guardian responsible for account?	Actions
						Edit Delete
There are no Parents/Guardians.

Maximum number of parents/guardians reached.

Siblings

Name	Age	Actions
		Edit Delete
There are no Siblings.

Maximum number of siblings reached.

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?

Self-Referred

I have a Referral

Family Dentist / School Dental Therapist(Required)

RESPONSIBLE PARTY FOR ACCOUNTS

Who is responsible for accounts and pre-treatment fees?(Required)

Patient/Self

Parent(s)/Guardian(s)

Other(s)

Please enter the information of person(s) or party(s) responsible for account below.

Name	Work	Mobile	Email	Address	Actions
					Edit Delete
There are no persons/parties.

Maximum number of persons/parties reached.

EMERGENCY CONTACT (SOMEONE OTHER THAN THE BILLING PARTY)

Name(Required)

Relationship(Required)

Phone(Required)

CONSENT

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

YES

MEDICAL HISTORY

Family Doctor

Are you currently under any medical treatment?(Required)

Yes

Are you taking any medications including herbal?(Required)

Yes

Have you ever had any serious illness and/or operations in hospital?(Required)

Yes

Have you had any allergic reactions to drugs or medications?(Required)

Yes

Do you have any allergies eg. nickel or latex?(Required)

Yes

Are you pregnant? (female only)

Yes

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

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(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 jaw, face or head.

My jaw clicks, pops, or locks when I open my mouth.

I have or have had difficulty in opening and/or closing my jaw.

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

The Dentist

I visit the dentist/school dental therapist regularly, at least every ________ months.

I visit the dentist/school dental therapist regularly, at least every months.

Or it has been ________ years since I had my teeth checked by the dentist.

Or it has been years since I had my teeth checked by the dentist.

The Orthodontist

This is my first experience with an orthodontist.

I have worn braces before ________ year(s).

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 delay treatment as long as possible.

Do you have any questions or information for us?

PATIENT INFORMATION

RESPONSIBLE PARTY FOR ACCOUNTS

EMERGENCY CONTACT (SOMEONE OTHER THAN THE BILLING PARTY)

CONSENT

MEDICAL HISTORY

TREATMENT ATTITUDES AND EXPECTATIONS

The Dentist

The Orthodontist

Expectations

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