Private and Confidential – Medical History

This form collects important personal information and alerts us to any medical condition, medication or other factors that may affect your orthodontic treatment. This information is handled with confidentiality and sensitivity. If you are uncomfortable filling some details on form, please let us know that there is something to discuss privately.



Fields marked * are required.

Patient information

Medical History

Dental History

Smile Evaluation

We respect your privacy

Orthodontic records including x-rays, photographs, clinical details, medical and dental history, and personal information are necessary to provide you the best orthodontic care in our practice. Occasionally it may be necessary to provide your information to relevant third parties. Examples of this would be your health fund asking for the date treatment commenced, a friend or relative confirming appointments, etc.

Your records may also be used for consultation with other medical and dental professionals in order to provide you with the best and most up to date treatment possible.

As well as being required for orthodontic and legal purposes your records can be useful for education, professional peer review and research purposes. Individual patients are never identified and your privacy and anonymity are protected.

Care is taken to ensure that your records are handled with confidentiality and sensitivity according to guidelines developed from the Privacy Act 1988.

If you wish to vary this consent we will require written advice from you.

Use the space below to note any specific requirements you have regarding how your personal information is used.

Please also specify (if any) persons who must not be provided with information regarding your treatment.

If you understand and accept the above, please sign below to show your consent. (If patient is under 18 a parent or guardian must sign and print their details on behalf of the patient)

Cancellation Policy

I understand that failures to appointments without at least 48 hours notice will incur a no-show fee of $70.

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

Find us in Nundah

Wired Orthodontics
1359 Sandgate Road
Nundah QLD 4012
Free parking available

07 3260 6855

Contact us