Patient Registration Form

Please complete the form below prior to your appointment so our team can prepare for your visit and provide personalised orthodontic care from the moment you arrive. If you have any questions while completing the form, please don’t hesitate to contact our friendly team.

Patient Information

Person Responsible For The Account

Existing Dentist and or Referring Doctor

Who Referred You?

Certain medical conditions or medications may have an impact on your orthodontic treatment. We also strive to ensure optimum infection control in our practice. As such, it is important to let us know if you have any infectious conditions. This will allow us to take the necessary precautions before commencing treatment.

Have you ever had a history of the following? (If so, please provide further details)

Medical Conditions