Lavrin & Lawrence Orthodontics :: Child medical history
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For further information about how we use your data, please see our privacy policy

You can either fill in the online form below or print it off at home and fill it in.


Patient information

Patient's medical history

(Please tick where applicable)

Contact information

Dental and Insurance information

Who can we thank for referring you?

How did you discover L&L Orthodontics?

Where have you seen L&L Orthodontics advertised?

What’s the main reason for choosing to book an appointment at L&L orthodontics?

What are you wanting to change about your smile?

Parent details

Parent/Guardian 1

Parent/Guardian 2

Person responsible for fees*

Patient's dental history

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

By submitting this form, you are confirming that to your knowledge, the information provided is complete and correct.

Authority to request/refer records to health care providers

We may need to request records from your previous or current dentist or specialist to assist with your orthodontic planning. We also correspond and forwards x-rays to your dentist or other specialists for treatment planning when required. During your treatment, we may need to refer you to other specialists. To ensure compliance with Federal and State Privacy Legislation we require your signed consent to work with other health care professionals.

Permission to take diagnostic x-rays

Client over 18 to sign OR Responsible Party to sign

Book your orthodontic consultation

  • One on one consultation with our specialist orthodontists
  • Recommendations for treatment options
  • Personalised treatment plan and affordable costs

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

Before & Afters

Before and afters

See the kinds of issues we have helped resolve for some of our patients in our smile gallery.

Costs & Finance

We’ll work with your family budget to find the best payment plan for your orthodontic treatment.