Patient Forms
(08) 9297 6823
REFERRALS

Treatments
Costs
Results
For Patients
About Us
Contact Us

REFERRALS BOOK A CONSULTATION

BOOK A CONSULTATION

Child form

If your child is a new patient to Ellenbrook Orthodontics, please fill out the form below.

Field marked with * is required.

Patient details

First Name*

Last Name*

Patient DOB*

Patient Address *

What school does the child attend?

Parent or Guardian Contact Details

Parent's Email*

Parent's Phone*

Private Health Insurance

Do you have private health insurance?*

Yes

No

If yes, Name of Private Health Insurance Company

Medicare Card Number

Child's Medicare Number

Child's number on medicare card

Medicare Card Expiry date (MM/YYYY)*

Dental and Orthodontic Questions

What is the reason for bringing your child to the orthodontist? *

How did you hear about us? *

Have we treated another member of your family?

Who is your child's general dentist?

Has your child seen an orthodontist previously?

Yes

No

Name and suburb of previous orthodontist

Dental questions

Has your child had any previous trauma or injuries to their face or mouth?

Does your child have any of the following habits?

Grinding teeth

Mouth breathing

Dummy sucking habit

Nail biting

Tongue thrust

Clenching habit

Sucking habit (finger/thumb)

Chewing/eating problems

Speech problems

Other

Does your child get any pain or tenderness in their jaw joint (TMJ/TMD)?

Does your child have many sweets or soft drinks in their diet?

None

Occasionally

Often

Daily

Multiple times a day

Patient Medical History

Please list any drug or other allergies the child has

Has your child ever had (please check all that apply)?

Asthma

Arthritis

Bleeding disorders (including excessive bruising or bleeding)

Cancer

Diabetes (please specify Type below)

Digestive or GI problems

Epilepsy or seizures

Fainting spells

Heart disease

High blood pressure

Hepatitis

HIV/AIDS

Kidney disease

Lung disease

Liver disease

Mental health (depression, anxiety etc)

Neurological disorders

Sleep apnoea

Thyroid problems

Not applicable

Other illnesses or further details

Is your child receiving any medical treatment? Please describe

Has the child had any operations in the last 12 months?

Please list your child's current medications

Is there anything else we should know regarding your child's medical history?

Sleep questionaire

Intended to help diagnose sleep disorders. Please score the child according to how often you have observed the following in the child on a scale from 1 (never) to 5 (always).

Guardian/Parent Responsible for the Account

Will there be multiple parties financially responsible for the account?

Yes

No

1st Guardian/Parent Responsible for the Account

Relationship to the client *

First Name*

Last Name*

Reponsible Party Address

Responsible Party Phone Number

Responsible Party Email

2nd Guardian/Parent Responsible for the Account

Relationship to the client *

First Name*

Last Name*

Reponsible Party Address

Responsible Party Phone Number

Responsible Party Email

Signature

In signing this form, I acknowledge that this represents an accurate medical history. I will also supply my dentist/orthodontist with any relevant changes to this history as required. All medical information will be treated with complete professional confidentiality within the guidelines of the Privacy Act 12/01 and through the obligations health service providers have under the Professional and Ethical Codes of Practice

Today's Date

Please sign here:

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

CONTACT US

Ready to transform your smile? Contact us!

Start your smile journey in Ellenbrook today.

Ellenbrook Orthodontics

62 Mornington Pkwy,
Ellenbrook WA 6069, Australia

reception@ebortho.com.au

Open in Google Maps

Opening Hours

Monday - Friday: 8:00am - 5:00pm
Saturday - Sunday: Closed

Smile for life

©Copyright 2025
Ellenbrook Orthodontics
All Rights Reserved
PRIVACY POLICY
COOKIES POLICY
Terms and Conditions