Medical history form

When starting a new treatment plan, we'll need a medical history for the patient.

If you've been directed here by our staff, or would just like to get started, please fill in the form below. This will be uploaded to our system ready for your first appointment.

Patient details

Financial information

Please complete the details of the person responsible for the account

Emergency contact

Medical history

We follow strict infection control protocols to prevent cross contamination and all instruments are put through a sterilization process before every procedure.

The information collected by our practice will be used for the purpose of providing treatment to you. Personal information will be used to address accounts to you, process payments and write to you about our services and any issues affecting your treatment.

Start your journey to beautiful teeth and
better alignment today.

(You don't need a referral)

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