Make an Appointment

Do you want to fill out the Patient Questionnaire now?

No, you already have my records
I will do this later
Yes Please

Patient Name*

First Middle Last

Parent Name

First Last

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address

same as my home address
is a different address

Postal Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If different to home address*

Home Phone

Patient D.O.B.

Mother's Name

First Last

Mother's Phone

Can be a cellphone / work phone if different to the home phone.

Father's Name

First Last

Father's Phone

Can be a cellphone / work phone if different to the home phone.

Email Address*

Name of Patient's School/Polytechnic/University

Name of Referring Person

First Last

Patient's Dentist/School Dental Therapist

Is the patient currently taking any medicines or tablets?

No
Yes

Please Specify which medicines or tablets

Does the patient have any infectious diseases at present?

No
Yes

Please Specify which infectious diseases

Has the patient got any other serious illnesses at present?

No
Yes

Please Specify which illness

Is the patient in the high risk group for Hepatitis or AIDS?

No
Yes

Please Specify

Does the patient have a bleeding disorder?

No
Yes

Please Specify

Is the patient allergic to anything?

No
Yes

Please Specify

Has the patient been in hospital or had any medical treatment in the last 6 months?

No
Yes

Please Specify why

Has the patient ever had any accidents or operations involving the mouth or face?

No
Yes

Please Specify

As an X-ray may be taken, is the patient pregnant?

No
Yes

Is there any other health matter that you would like to discuss with the Orthodontist?

No
Yes

Location*

Has the patient ever had any of the following? If so, please tick as appropriate

Confirmation**

By typing my name out below I am acknowledging that all the above medical information is true to my knowledge. I will settle all accounts from Hutt Valley Orthodontics within a reasonable period of time. If not, I acknowledge that I will be liable for interest/debt collection fees or other fees which may be involved in the recovery of any outstanding debt.

First Last

*

Message

Appointment Form

We can’t wait to see you!