Medical History Form | Sydney Specialist Orthodontist | The Ortho Practice

Medical History Form

To ensure we have all the information we need for your first visit, please fill out the appropriate health history form below and bring this with you on the day.

Fields marked * are required.

Patient Details

Billing/ Responsible Party Details

Dental History

Medical Information

Privacy Collection Statement to see how we use your personal information.

The Ortho Practice collect, handle, use and protect your personal information in accordance with the Privacy Act 1988 (Cth) and our Privacy Policy which can be viewed in full https://mavendental.com.au/privacy-policy. Or please ask our reception team for a copy of our Privacy Policy.

We collect your personal information to provide you with products and services you have requested, improve our products and services, keep you informed of your upcoming appointments and notify you about our latest promotions and other offers relevant to you. We collect this information mainly through our communications with you, but we may do so also from other sources in the course of providing our services to you. You are not obliged to provide us with your personal information, however this may impact our ability to provide you with our products and services. We generally do not disclose information about you to any person and will only share your personal information where necessary to provide you with products and services, as required by law, or with your permission. Our Privacy Policy sets out how you can access and change your personal information or make a privacy complaint.

If you would like us to send you a copy of our Privacy Policy, inform us that you do not wish to receive promotional material from us, request access to or the correction of information we hold about you or to make a complaint about our treatment of your privacy, please contact us by email at notices@mavendental.com.au by phone on +61 (07) 5635 2000 or by mail to The Privacy Officer, Maven Dental Group, PO Box 1146 SOUTHPORT BC QLD 4215.

By clicking ‘Submit’ you are agreeing to our privacy policy.

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Sydney CBD practice

Park House – Level 10,
187 Macquarie Street,
Sydney,
NSW 2000

(02) 9344 7081

Maroubra practice

Level 1 822 Anzac Parade
Maroubra
NSW 2035

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84 Avoca Dr
Kincumber
NSW 2251

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