New Patient Form

Contact Details

Emergency Contact

Secondary Emergency Contact

If patient is under 18, secondary parent/carer details (if applicable)

Medicare and Health Funds

Financial Information

Secondary Financially responsible party (if applicable)

Medical History

Dental History

Treatment Preference

Payment Preference

• We offer interest-free payment plans
• If appropriate, we may be able to set up your payment plan during your appointment
• Deposit required if not paying in full

How did you hear about L&L Orthodontics?

Patient Record & X-Rays

Please attach records or referral here

At L&L Orthodontics, we use a secure AI clinical documentation tool during your consultation. The AI securely converts your conversation into clinical notes, helping our team provide a more focused and personalised consultation while maintaining accurate clinical records.

If you would prefer not to have this technology used during your consultation, please let our team know.

Patient Acknowledgement

By submitting your details and signing below, you:

• confirm that the information you have provided is complete and accurate;
• confirm you have read, understood and agree to our Privacy Policy which can be accessed here;
• confirm that we have your permission to take diagnostic x-rays and digital records;
• acknowledge that we may need to correspond with and request records from your previous/ current dentist or specialist to assist with treatment planning, and to correspond with and forward x-rays to specialists as needed. You provide your consent to us taking these steps;
• acknowledge that we may need to refer you to other specialists during your treatment;
• provide your consent to receiving marketing materials from L&L Orthodontics via email and SMS. You may opt out of receiving these at any time.

Patient over 18 years (or Responsible Party) to sign: