Medical History Form | 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

*We also recommend you check with your health fund ahead of the consultation for any orthodontic treatment cover you may have. We have provided the item numbers for our most common treatments for you in question 2 (Braces item number 881 and Invisalign item number 825x2)

Billing/ Responsible Party Details

Dental History

Medical Information

Please tick any that apply to you:

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.

Consultation Note - Taking Notice

To assist with accurate clinical documentation, our practice uses Heidi Health, a secure medical note-taking application, during consultations. Heidi Health helps our clinicians efficiently capture and organise consultation notes, whilst maintaining patient privacy and confidentiality. If you have any questions about how Heidi Health is used in our practice, please let our reception team know and they will be happy to assist.

Patient Consent

At The Ortho Practice, we record consultations using secure and compliant professional software to ensure accurate documentation of treatment discussions, recommendations, and your questions. These recordings help us maintain precise clinical records to provide our team with an accurate reference of what was discussed during your consultation, and allow us to continuously improve the quality of care we deliver.

By checking the ‘Yes – I consent’, I acknowledge and consent on my behalf, or on behalf of the person who has authorised me to provide consent, to the following:

The Ortho Practice collecting my personal information (including sensitive and health information) through the recording of my consultation for the purpose of maintaining precise clinical records;

  • The Ortho Practice using and disclosing my personal information (including sensitive and health information) for the purpose of maintaining accurate documentation of treatment discussions; and
  • The Ortho Practice disclosing my personal information (including sensitive and health information) to third parties, such as Gong.io Inc, so that these third parties can securely store consultation recordings on The Ortho Practice' behalf.

Recording will involve the collection of your personal and health information through sound recording.

All recordings will be securely stored by our service provider, Gong.io Inc, on cloud servers in the United States. Our service providers will only access the recordings to provide technical support and system maintenance. More information about Gong.io Inc's privacy practices is available at: FAQs: Security, Privacy and Compliance

To learn more about how we handle your personal information, how to request access to, or correction of, your personal information, how to make a privacy complaint and how we will deal it, please view our Privacy Policy at Gong Privacy Policy or contact the team at Reception.

You are not required to agree to the recording of your consultations, and if you do not agree, it will have no impact on the provision of our services to you.

By submitting this form, you are agreeing to our privacy policy.

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