Call: (03) 9088 4131 | Level 1 455 Auburn Rd, Hawthorn VIC 3122

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Medical & Dental History

Please complete the form below, before your first appointment.

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Medical & Dental History

Dental History

Patient details

Home Address
Home Address
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Mailing Address (If Different)
Mailing Address (If Different)
City
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Contact details

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This is your individual reference number on the Medicare card

Medical/Dental History

Medical History
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Dental History
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Other information

Has an Orthodontist been consulted previously?
How did you hear about us?

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