Melbourne CBD (03) 9650 0037 Templestowe (03) 9846 3811
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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

Title *
Gender *
Have any other family members had treatment at L&L Orthodontics?

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

Is someone else financially responsible for your treatment or are you under 18 years of age? *

Secondary Financially responsible party (if applicable)

Medical History

Please tick where applicable

Pregnant / Expected Pregnancy

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.