Teleconsultation Patient Information Form

Step 1. Photos saved on your phone

Step 2. 

Patient Teleconference form

IMPORTANT

Does your child have a fever, cough, or difficulty breathing *
Have you or your child been in contact with any suspected or known cases of COVID-19 *

Patient information

Have you been to see us before?
Address *
Address
Suburb
State
Postcode
Country

Parent details

Legal guardian *
Has a written referral been provided? *

Private Health Fund

Do you have Private Health Insurance

Medicare details

Medical History

Has your child had a previous General Anaesthetic? *
Is your child taking any medications?
Does your child have any allergies, including drugs, medications and latex?
Are your child’s immunisations up to date? *
Please tick the following that apply to your child

Dental History

Is your child currently experiencing any pain? *
Did your child have an accident and injure their teeth? *

Attach 5 photos

Patient’s upper right back teeth
Maximum upload size: 3MB
Patient’s upper left back teeth
Maximum upload size: 3MB
Patient’s lower left back teeth
Maximum upload size: 3MB
Patient’s lower right back teeth
Maximum upload size: 3MB
Front teeth with lip lifted
Maximum upload size: 3MB

Agreement

Please be advised that a $55 fee will be payable to the reception at the time of booking. By submitting this for I acknowledge, to the best of my knowledge, all the preceding answers are true and correct. *