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

Who can we thank for referring you?*

Dental Practitioner

Internet

Word of mouth

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Parent details

Father or Guardian

Mother*

Person responsible for fees*

Patient's dental history

Patient's medical history

(Please tick where applicable)

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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.







Book your orthodontic consultation

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

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The Orthodontist consultation is particularly recommended for children under 13yrs, adults who have not had previous orthodontics treatment, people with jaw alignment issues & people with gum disease.

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.