Patient medical forms

Name: Braces N Faces Orthodontics
Telephone: (03) 5221 6677

Please complete the below forms before your consultation so we can have this information ready before you begin treatment. If you have any questions, please call us on (03) 5221 6677 (Geelong) or (03) 9748 9224 (Hoppers Crossing).

Fields marked * are required.

Patient Details

Preferred practice location* Geelong Hoppers Crossing

Responsible Party Information (The Person who is responsible for paying for your treatment)

The payment plans we offer are based on the information you provide below and are designed to help you.
If you do not wish to complete this section below, then we shall be very limited in the financial arrangements we can offer you.

Or, please provide details if responsible party is different to patient:

First Responsible Party Details

Responsible Party First Name

Responsible Party Last Name

Date of Birth

Relationship

Home Address

Postcode

Phone No (H)

Phone No (W)

Phone No (M)

Employer/s

Occupation/s

Second Responsible Party Details