Medical History Form | Central Coast Orthodontists | 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

Office use only

Billing/ Responsible Party Details

Dental History

Medical Information

Your Health Information and our Privacy Policy

Our practice respects your right to privacy. It is important that you understand the purpose for which we collect details about you and your health, as well as how this information is used at our practice and to whom this information might be disclosed. More detailed information is set out in our Privacy Policy. If you would like a copy of the policy please ask our staff.

The information we collect will be used for the purpose of providing treatment to you. Personal information such as your name, address, telephone numbers, email address and health insurance details will also be used for the purpose of billing and processing payments. Unless you tell us you do not want to receive information from us, we will also use these details to keep you updated about our services and advise you of other products and services relevant to your dental and general health.

Unless required to do so by court order or other legislative requirement, we will only collect, use and disclose your health information for the purposes of assessing, advising and treating you. We may also use parts of your health information for staff training, professional development, quality improvement and dental health research. Your personal identity will not be disclosed without your consent to do so or, if this is not possible, with the approval of an ethics committee.

Your patient history, treatment records, x-rays and any other material relevant to your treatment are kept in both a written form and in electronic clinical information systems. Our practice is part of a larger software management, Dolphin Management Software who assist us with the management, storage and operation of our clinical information and data systems.

We have security measures in place to protect this information against unauthorised access or use and damage, theft or other loss. We may use contracted external providers to assist us with this data storage, access and use. These providers are based both in Australia and in America.

You may inspect or request copies of your treatment records at any time, or seek an explanation from the dentist. If you want copies, a fee may apply. If you require a detailed explanation of your records or a written summary, a consultation fee or other charge may apply.

It is important that the information we hold about you remains accurate. Please advise our staff if your contacts details change. If any of the information we have about you is inaccurate, you may ask us to alter our records accordingly.

If you have any queries or concerns about our handling of your health information, please do not hesitate to raise these concerns with our practice.

Please sign below to confirm that:

  • you have read this information;
  • you agree to our collecting, using and disclosing your information in this way.

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

Diamond Invisalign  provider

Dental monitoring

Quality innovation performance

Sure smile Aligners

Give a smile

Australian Dental Association

The Invisible Orthodontist

Find Us

Maroubra practice

Level 1 822 Anzac Parade
NSW 2035

(02) 9344 7081

Kincumber practice

84 Avoca Dr
NSW 2251

(02) 4369 2209