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Child Patient Medical History Form

Helping Us Provide the Safest, Most Personalised Care
Welcome to Hunters Hill Orthodontics. To ensure we can provide your child with the safest, most effective, and most personalised care possible, we require all new child patients to complete a comprehensive medical and dental history form before their first appointment.

Please complete this form in full before your consultation so you won’t need to complete it again when you arrive *

Patient Information

Gender *
Are you in a Health Fund? *

Parent/Guardian 1 *

Parent/Guardian 2

Emergency Contact

Dental Practitioners

Person Responsible for Account Payment

If other than above

How did you become acquainted with our Practice? *

Medical History

Do you suffer from any of the following medical conditions? (Please tick)
Have you had any serious illnesses other than those above? *
Are you allergic to any food, drug or medicine? *
Are you allergic to Latex? *
Are you allergic to Nickel? *
Are you currently taking any medication? *
Have you had any kind of orthodontic treatment previously? *
Have you had any past injury to the face, jaws or teeth? *
Do you suffer from any jaw discomfort? *
Do you grind your teeth at night? *
Do you snore at night? *
Do you sleep with your mouth open? *
Have you had your tonsils or adenoids removed? If so, at what age? *
Did you ever suck your thumb or fingers? If so, until what age? *
Do you, or did you, have any other oral habits (nail biting, lip biting)? *
Are you concerned about your orthodontic condition? *
Do you play any wind instruments? *
Please sign here:

By clicking Submit, you are agreeing to our privacy policy.

Visit Us

Our team in Hunters Hill is here to help you book an appointment or answer any questions you may have.

Location58 - 60 Gladesville Rd
Hunters Hill NSW 2110

Phone(02) 8054 2722

Emailinfo@huntershillorthodontics.com.au

Opening timesOpening Times
Monday - Thursday
8:30am - 5:30pm

If visiting the practice without an appointment, please call ahead.

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