New Patient Questionnaire

Kindly fill in the new patient questionnaire form below.

New Patient Questionnaire

Patient Data

Responsible Person for Payment

Responsible person for payment details as above
Private Health

Nearest friend or relative not living with you

Thank You

Dental Information

General Dentist details

Patient Concern

Previous Treatment

Have you had any previous orthodontic treatment?

Medical Questionnaire

Is the patient receiving any medical treatment at present?
Does the patient or has the patient ever suffered from:


Does the patient have any allergic reactions to latex, metal or plastic?
Does the patient suffer from any other allergies?
Do you take any medications?
Do you have any private or confidential matters you wish to dicuss with the orthodontist?
Is the patient in good health?
Females: Are you/could you be pregnant?
Do you smoke?


I the undersigned acknowledge that the information stated is true and correct and accurately represents the medical history of the person receiving treatment. If any personal or medical history changes I will notify Peel Orthodontics immediately to update my records.

In the event that the account is not paid within the clinic's standard trading terms, I/we agree to pay all late charges and any debt collection costs associated with the collection of these overdue fees.


Our Practice respects your rights to Privacy. We realise that it is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our Practice and to whom the information might be disclosed. The Full Privacy Policy is available from our website at or please ask reception for a copy.

  • If consent to treatment is withdrawn before starting the proposed treatment, any expenses incurred for laboratory fees, administration services, appliance fees or any other expenses will still be payable.
  • The information collected will be used for the purpose of providing treatment, or to process accounts, payments and writing to you about our services and any issues affecting your treatment.
  • We may disclose your health information to other health care professionals, or require it from them if, in our judgement, that is necessary in the context of your treatment. In that event, disclosure of your personal details will be minimised wherever possible. I understand that once released, Peel Orthodontics has no responsibility for any release by the individual receiving this information.
  • We may also use part of your health information for research purposes, in study groups or at seminars that may provide benefits to other patients. Your personal identity will not be disclosed without your consent to do so.
  • You may have the right to access personal information that we hold about you. You can contact us in writing, by email or by telephone and request access to personal information. Our contact details are set out in Section 8 of the Privacy Policy. We will always try to meet your request within a reasonable time. In some circumstances, your request for access may be denied, please see Section 6 of full policy details. If any of the information we have about you is inaccurate, you may ask us to alter our records accordingly. You can otherwise rest assured that your health information will be treated with the utmost confidentiality. We will disclose your personal information to third parties if you have agreed that we can do so. Please refer to Section 5 of the full policy document for details. If you have any queries or concerns about our handling of your health information, please do not hesitate to raise these concerns with our Practice. Otherwise, please sign the form as confirmation that you have read and understood our Privacy Policy, and consent to the use of your health information in this way.

Use of clinical photographs and records

Here at Peel Orthodontics, we are proud of the smiles we create for you. We would love to show off your smile, not just for their gorgeous looks, but also for education and scientific purposes. The mediums in which this could happen include, scientific journals and lectures, our web page and our in-practice presentations. We are committed to providing you with excellence in orthodontics and consider continuing education and keeping updated in the latest orthodontic technology an integral part of this. Please give us permission to use your clinical photographs, as this will allow us to contribute to the improvement of orthodontics worldwide. I consent to the photographic records being available for use by Peel Orthodontics for the reasons listed above.

I agree to use of clinical photographs and records

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