Name: Ipswich Orthodontics
Telephone: 07 3812 0865

Title* Mr Mrs Miss Ms

Is your child currently on any medication * Yes No

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Is your child under the care of a Medical Practitioner * Yes No

Does your child have any allergies * Yes No

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General Dentist/School Dentist Name*

When was your last dental check-up* Less then 6mths ago 6-12mths ago 12-24mths More then 24mths

Please tick if your child has had any of the following *

Please tick if you have any of the following*

Any other illness/disability not listed above: * Yes No

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Has your child had any jaw pain or clicking * Yes No

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Has your child had any speech therapy * Yes No

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Has your child had any recent rapid growth * Yes No

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Is there any Family dental traits * Yes No

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What is your main concern in seeking this appointment *

How did you hear about us *

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Relationship to child*

Relationship to child

Person completing this form*

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Australian Dental Association

Royal Australian College of Dental Surgeons

Damon Smile

Australian Society of Orthodontists

Invisalign

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13 South Street
Ipswich
QLD 4305

07 3812 0865

Directions & Opening Times Contact us

Child Patient Medical History

Medical History

Dental History

Parent/Guardian contact #1

Parent/Guardian contact #2

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