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Patient Information

Person Responsible For The Account

Existing Dentist and or Referring Doctor

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 you have ticked any of the following please provide details)

Medical Conditions