Melbourne CBD (03) 9650 0037 Templestowe (03) 9846 3811
Book a Consultation Book a Consultation Book a Consultation 3 Minute Assessment
Book a Consultation

New Patient Form

Welcome to L&L Orthodontics!
To help us get everything ready for your first consultation, please complete the form below before your visit.

Patient Information

Contact Details

Emergency Contact

Medicare and Health Funds

Do you have Medicare? *
Do you have private health insurance? *

Referral Information

Do you have a dentist referral? *
Have you had a dental check up in the last 12 months? *

Financial Information

Secondary Financially responsible party (if applicable)

Medical History

Please tick where applicable

Dental History

Have you had past orthodontic treatment? *
Is this a second opinion? *

Treatment Preference

Do you have a treatment preference? *
How soon would you like to start treatment? *
Do you need or wear a mouthguard for sport? *

Payment Preferences *

  • We offer interest-free payment plans up to 20 months
  • We can get you started on the day
  • 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
(file types: jpg, gif, png, pdf (up to 5 files only; max file size 10MB)

Drop files here or,
Select Files

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;
  • 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:

For further information about how we use your data, please see our privacy policy.