Surname:
Name:
Gender:
Age:
Date of Birth:
ID
Home Address:
Code:
Home Tel No:
Fax:
Cell:
School:
Grade:
Email:
Reason for seeking Treatment(What concerns you most about your teeth?)
Has the patient had a previous orthodontic consultation or treatment?NoYes
[group group-prev-treatment clear_on_hide]
Date:
Dr:
[/group]
SURNAME: Prof. /Dr. /Rev. /Mr. /Mrs. /Miss:
ID No:
Postal Address:
Place of Employement:
Occupation:
Work Tel No:
Martial Status:
Relationship to Patient:
Medical Aid:*
Plan:*
Number:*
* If parents are divorced/separated the written consent of the main member of the medical aid is required before treatment may commence
Father's name & surname:
Contact Tel No's:
Mother's name & surname:
Has the patient ever had?AllergyAnemiaArthritisAsthmaBleedingCancerCold SoresDiabetesEndocrine ProblemsEmotional ProblemsEpilepsy SeizuresHeadache/MigraineHeart ConditionHead or Face InjuryHepatitisHerpesHIV PositiveKidney DiseaseOral UlcerPrevious SurgeryRheumatic FeverThyroid ProblemsTuberculosisOther
Relevant Comments:
Does the patient require any premedication for dental procedures?
Has the patient had:
Nasal Surgery
Tonsils removed
Adenoids removed
Patient's Dentist
Has the patient had any unusual dental experience?NoYes
Date of last dental check up
Were patient's teeth cleaned then?
Does the patient have any TMJ (“Jaw Joint”) problems?NoYes
The following habits are of interest in orthodontics
Thumb sucking:NoYes
Finger sucking:NoYes
Lip sucking:NoYes
Grinding of teeth:NoYes
Nail biting:NoYes
WHOM MAY WE THANK FOR REFFERING YOU TO OUR OFFICE?
Benefits of Orthodontics: Aesthetics, Health and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph; I also understand that the abovementioned patient's diagnostic records and name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Cara to perform a complete orthodontic evaluation.
Vision House, Cnr Parklands Main Road & Hampstead Close, Parklands, Cape Town
Phone: +27 (0)21 556 6789
Email: Email For An Appointment
Web: Website
