Brace5 – Breace5

Medical History

It is important to know details about your medical history as these could affect the success of your Orthodontic treatment and how we can provide this treatment safely for you. The information you provide is confidential and will be handled in accordance with our strict privacy policy.

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Name

Title*

First*

Last*

Patient Email

Street Address City Post Code

Date of Birth*

Sex*

Who Is Your Current Dentist

Occupation/Name of School*

Year

Health Fund*

Home

Work

Mobile*

Email (Required)*

Person Paying Account*

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How many brothers/sisters*

Names and ages of siblings

Sibling 1

Name Age

Sibling 2

Name Age

Sibling 3

Name Age

Sibling 4

Name Age

Sibling 5

Name Age

Have you ever had any of the following, if so, please tick and give any relevant details:

Select*

More Info

Have you been hospitalised in the last 12 months?*

Yes
No

Have you had a general anaesthetic or operation of any kind?*

Are you being treated by a doctor at present?*

Are you taking any prescription medications at present?*

None
Do you smoke?
Do you drink alcohol?
Have you ever used drugs (intravenous or other)?

Are you pregnant or is there a possibility that you may be pregnant?*

Yes
No
Maybe

Pregnancy Due Date*

Is there any other relevant information that you may wish to discuss with Dr Mamutil?*

Yes
No

Relevant Information

How did you hear about Brace5?*

Name of Person / Doctor that Referred You*

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