Medical Questionnaire

Patient Name*
Title Given Name Surname
Address*
Address Suburb Post Code
Home Ph
Work Ph
Mobile Ph*
Mobile number you would like your SMS appointment notifications sent to*
Email*
Date of Birth*

Day
Month
Year
Health Fund (if applicable)
School/University Attending (if applicable)
Year
Dentist Name
Name of Dental Practice
Did Your Dentist Refer You?
Hobbies/Interests
Other family members that have been treated by Ethos Orthodontics
Relationship of family members that have been treated by Ethos Orthodontics
Newsletter Sign Up
- Please tick if you DO NOT wish to receive Ethos "email" Newsletter via the email address

In accordance with the Privacy Act, information pertaining to the patient cannot be given to any persons without authority. Please complete the section below if you wish any other person to have access to appointment and/or financial information. Please note, persons not nominated on this form will NOT be able to obtain any information.
Name
Title Given Name Surname
Relationship to the Patient
Phone
Please Check
- Appointments
- Financial
Name
Title Given Name Surname
Relationship to the Patient
Phone
Please Check
- Appointments
- Financial
*
- In accordance with the Privacy Act, information pertaining to the patient cannot be given to any persons without authority. Please complete the section below if you wish any other person to have access to appointment and/or financial information. Please note, persons not nominated on this form will NOT be able to obtain any information.
*
- I / We confirm that all of the above particulars are true and correct to the best of my / our knowledge and accept responsibility for the payment of our account.
*
- I / We acknowledge that it is my / our responsibility to inform Ethos Orthodontics of any personal, medical or financial changes.
*
- I/ We acknowledge that information will be provided to our my/our health fund and other medical/ dental practitioners if requested.

medical & dental history questionnaire