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Orthodontic Checkup

Child's Information

Child Date of Birth
Day
Month
Year
Gender
Male
Female
Expiry Date:
Day
Month
Year

Past/Current medical conditions

Are you receiving any medical treatment at present?
Yes
No
Have you had any serious or long standing illness?
Yes
No
Have you ever been hospitalized?
Yes
No
Any heart complaint/treatment
Yes
No
Rheumatic fever or heart values surgery
Yes
No
High or Low blood pressure
Yes
No
Blood disorder/bleeding disorders
Yes
No
Epilepsy
Yes
No
Diabetes
Yes
No
Familial diseases
Yes
No
Infectious diseases (measles/chicken pox) especially in the last three weeks
Yes
No
Tuberculosis
Yes
No
Any nervous system disorder
Yes
No
Asthma/bronchitis/lung conditions
Yes
No
Radiation therapy / chemotherapy
Yes
No
Thyroid disease
Yes
No
Hepatitis, jaundice or live disease
Yes
No
Treatment for any form of cancer
Yes
No
Transplanted organ or bone marrow
Yes
No
Kidney conditions
Yes
No
Is your child up to date with immunisations?
Yes
No
Allergies (eg. latex, penicillin, etc)
Yes
No

Parental Consent & Signature

I confirm that the above information is accurate to the best of my knowledge. I give consent for my child to receive dental care and treatment as needed.

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