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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Phone Number (other)
Format: .
Billing Party Address:

Street Address

SuburbState / Province

Postal / Zip Code
Is your billing address the same as your postal address?
Postal Address (if different to billing address)

Street Address

Street Address Line 2

CityState / Province

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

First NameLast Name
Relationship to Patient
Phone Number
Format: (000) 000-0000.
Medical Information:
Has the patient required antibiotic cover before dental treatment in the past?
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?
Please tick only if the patient has, or has ever had, any of the following:
Details of any other medical conditions?
Are you a member of a private health fund and have orthodontics cover?
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:
Dental History:
Current Dentist Name and Practice:
When was your last dental check up?
Please upload a referral Letter if applicable

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Are you currently in orthodontic treatment?
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

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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:
Do you consent to your consultation being recorded for Dr. Gullotta’s notes and treatment planning? Recordings are confidential.
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.
Should be Empty:

New Patient Medical Information Form

Consultation Information: