New Customer Registration Form

New Patient Medical Information Form

Please complete this form to save time at your initial consultation
Patient Full Name*

PrefixFirst NameLast Name
Preferred First Name
DOB*

DayMonthYear
Date
Gender*
Address*

Street Address

Street Address Line 2

SuburbState / Province

Postal / Zip Code
Phone Number*
E-mail*
School (if applicable):
Responsible Billing Party Details:
Billing Party Name*

First NameLast Name
Billing Party Date of Birth (required):*

DayMonthYear
Date
Relationship to patient:*
Billing Party Email:*
Billing Party Phone Number*
Phone Number (other)
Billing Party Address:*

Street Address

SuburbState / Province

Postal / Zip Code
Is your billing address the same as your postal address?

YesNo
Postal Address (if different to billing address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Party Phone Number:*
Alternative Contact/Emergency Contact: (if different to billing party)
Full Name

First NameLast Name
Relationship to Patient
Phone Number
Medical Information:
Has the patient required antibiotic cover before dental treatment in the past?*

YesNo
If yes, reason:
Any allergies including drug, gluten, nickel or latex, (Please type N/A if not applicable)?*
Please list any medication currently being taken (Please type N/A if not applicable):*
Is the patient currently pregnant?*

YesNo
Please tick only if the patient has, or has ever had, any of the following:*

NoneAsthmaDiabetesRheumatic FeverHeart murmurHeart disordersEpilepsyHepatitisLiver diseaseKidney diseaseHormone therapySpeech problemsBlood disordersTonsils/adenoids removedFacial traumaProsthetic ImplantsHearing problemsADHDNoise or Light Sensitivity (Flash Photography and XRays/Scans taken) Please elaborate in note below:Autism
Details of any other medical conditions?
Are you a member of a private health fund and have orthodontics cover?*

YesNo
If you have a private health with orthodontic cover, please specify which fund (Please type N/A if not applicable):*
What is your Medicare number? (N/A if not applicable)*
Medicare Reference number: (N/A if not applicable)*
Medicare Expiry: (N/A if not applicable)*
Are you an Australian Citizen:

YesNo
Dental History:
Current Dentist Name and Practice:*
When was your last dental check up?*
Please upload a referral Letter if applicable

Cancelof
Are you currently in orthodontic treatment?*

YesNo
Details of any orthodontic treatment past or current (e.g Braces or Invisalign):
Have you had any dental or orthodontic x-rays taken within the last 12 months (if so, what is the name of the clinic where these records were taken and do we have permission to access these x-rays on your behalf?)
Please upload any XRays if applicable

Cancelof
When do you wish to commence orthodontic treatment? Is this something you'd like to start as soon as possible?*
Has anyone else in the family seen Dr Gullotta?
If referred by patient/friend, please specify who:
How did you hear about us?
If Google, please specify what you Googled.
Consultation Information:
I am aware your comprehensive treatment options range from $9,000 to $12,000, with additional fees for more complex treatments. For younger patients who may need Phase 1 treatment the fee range is typically $2,500 - $5,500:*

YesNo
Do you consent to your consultation being recorded for Dr. Gullotta’s notes and treatment planning? Recordings are confidential.*

YesNo
By clicking submit I authorise Gullotta Orthodontics to provide relevant information to other health care professionals regarding patient care and treatment. I authorise Gullotta Orthodontics to provide financial information to health insurance agencies.
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New Patient Medical Information Form

Consultation Information: