We will be closed from 20th December and will re-open on 6th January, 2025. In an emergency, please contact or leave us a message. We wish you and your families a safe and very Merry Christmas and a Happy New Year!

Geelong

(03) 9748 9224

Hoppers Crossing

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Geelong (03) 5221 6677

Hoppers Crossing (03) 9748 9224

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Patient medical forms

Name: Braces N Faces Orthodontics
Telephone: (03) 5221 6677

Please complete the below forms before your consultation so we can have this information ready before you begin treatment. If you have any questions, please call us on (03) 5221 6677 (Geelong) or (03) 9748 9224 (Hoppers Crossing).

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Patient Information
Medical Forms

Fields marked * are required.

Patient Details

Preferred practice location* Geelong Hoppers Crossing

Gender* Male Female Prefer not to answer Not listed

Preferred Pronoun* He She They Prefer not to answer Not listed

Patient's First Name*

Patient's Last Name*

Date of Birth*

Home Address*

Suburb*

Postcode*

Phone No (H)*

Phone No (W)*

Phone No (M)*

Email Address*

Patients School / University

If patient is a minor, please give parent(s) or Guardian’s names:

Patient lives with: Parent(s) / Mother / Father / Self /Other*

Family Dentist

Who referred you to our practice?

Medicare number

Reference

Are you covered for Orthodontic Treatment by private health insurance?* Yes No

If so, name of insurer

Responsible Party Information (The Person who is responsible for paying for your treatment)

The payment plans we offer are based on the information you provide below and are designed to help you.
If you do not wish to complete this section below, then we shall be very limited in the financial arrangements we can offer you.

Or, please provide details if responsible party is different to patient:

First Responsible Party Details

Responsible Party First Name

Responsible Party Last Name

Date of Birth

Relationship

Home Address

Postcode

Phone No (H)

Phone No (W)

Phone No (M)

Employer/s

Occupation/s

Second Responsible Party Details

Responsible Party First Name

Responsible Party Last Name

Date of Birth

Relationship

Home Address

Postcode

Phone No (H)

Phone No (W)

Phone No (M)

Employer/s

Occupation/s

Other than the responsible parties listed above, are there any other individuals or legal guardianship arrangements, in place that require specific consent for the patient to elect treatment and/or who need to be involved in the ongoing management of the orthodontic treatment?* Yes (Our team will require a supplementary form to be completed) No

Emergency Information

Contact Person

Relationship

Phone No (H)

Phone No (W)

Phone No (M)

General Information

Has the patient had an orthodontic consultation before?* Yes No

If “yes” with whom

Has the patient ever had orthodontic treatment?* Yes No

If “yes” with whom and what was the treatment?

Any medical/behavioural conditions, allergies or illnesses?* Yes No

If “yes”, please give details

Have you had any problems with dental treatment?* Yes No

If “yes”, please give details

Have any other family members had orthodontic treatment with us?* Yes No

If “yes”, what is the patient’s name?

Are you taking any prescribed medication/s?* Yes No

If “yes”, please note medications

I understand that the above information will be kept strictly confidential.

Please sign here:

By submitting this form, you are agreeing to our privacy policy.

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First Name

Last Name

E-Mail Adress

Phone Number

For further information about how we use your data, please see our privacy policy.

Visit Us

452-456 Latrobe Terrace
Newtown
VIC
3220

(03) 5221 6677

Directions & Opening Times

92 Derrimut Rd
Hoppers Crossing
VIC
3029

(03) 9748 9224

Directions & Opening Times

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