Field marked with * is required.

Patient details

First Name*

Last Name*

Patient DOB*

Date of last visit

Patient Address *

Email*

Phone*

Health Information

Other conditions or further details

Please list any drug or other allergies

Please list your current medications

General Health Updates

Since your last visit, have there been any changes in your general health?*

Yes

If yes, please explain

Have you had any recent hospitalisations or surgeries?*

Yes

Have you been diagnosed with any new medical conditions?*

Yes

If yes, please provide details

Dental / Orthodontic Concerns

Have you had any pain, discomfort, or sensitivity?*

Yes

Have you had any problems with appliances (braces, aligners, retainers)?*

Yes

If yes, please provide details

Have you seen a general dentist or other dental specialist since your last visit?*

Yes

If yes, please specify

General dentist

Oral surgeon

Periodontist

Other

Parental Responsibility and Consent (for patients under 18 years)

If the patient is under 18 years of age, please complete the following:

I confirm that I am a parent/legal guardian of this child and am authorised to consent to orthodontic assessment and treatment.

I confirm that I have disclosed any court orders, parenting orders, custody arrangements, or legal restrictions that may affect:

consent for treatment
access to the child’s health information
who is permitted to attend appointments or make decisions

I understand that if any such legal arrangements exist, I am required to provide a copy of the relevant documentation prior to or at the appointment.

In the absence of this information, I understand that Ellenbrook Orthodontics will assume that:

either parent/legal guardian may consent to treatment
either parent/legal guardian may access the child’s records
either parent/legal guardian may attend appointments and make decisions regarding care

I understand that the practice is unable to become involved in family or legal disputes and will rely on the information provided.

I confirm that the information provided in this form is true and complete to the best of my knowledge.

Patient / Parent Signature

In signing this form, I acknowledge that this represents an accurate update to my 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

Printed name*

Today’s Date

Please sign here:

By submitting this form, you are agreeing to ourprivacy policy.

Medical History Update Form

Patient details

Health Information

General Health Updates

Dental / Orthodontic Concerns

Parental Responsibility and Consent (for patients under 18 years)

Patient / Parent Signature

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Ellenbrook Orthodontics