Pre-first-visit Health History Form

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Tygervalley • Monday – Friday: 8:00 – 17:00 • Call us: 021 569 3477

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Pre-first-visit Health History Formadmin2021-07-14T06:44:23+00:00

Patient Biographical Information

Financial Party Information

Check if the patient is also the person who will be financially responsible for treatment.

Dental Insurance Information

Dental History

Has the patient had an orthodontic consultation or treatment?

Yes

Does the patient need to premedicate prior to dental visit?

Yes

Patient Motivation for Orthodontic Treatment

Straighten Front Teeth

Upper

Lower

Both

Straighten Back Teeth

Upper

Lower

Both

Move Upper Teeth

Forward

Backward

Move Lower Teeth

Forward

Backward

Eliminate Spaces Between Teeth

Upper

Lower

Both

Eliminate Crowding of Teeth

Upper

Lower

Both

Make Line of Upper Teeth More Level

Other

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Physical Address

Carbon House
Unit 10, Springfield Office Park
99 Jip de Jager Drive
Door de Kraal, Bellville

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Contact Us

Phone: 021 569 3477

Email: info@duraanorthodontics.co.za

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Important Forms

Please complete these forms before your first visit to our practice.

1. Pre-first-visit Health History Form
2. Full Health History Form

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