Medical & Dental History Form


For the team at South Yarra Orthodontics to properly treat you or your family, the details of your medical history is needed. Having your medical history can enable our orthodontists to treat you with optimal and personalised care.

For your convenience, we have our medical history form available to download and print or you can fill in the below form to submit it online.

Download your medical history form here 

  • Please indicate any of the following
  • Please indicate any of the following
  • If x-rays are required I, (patient / parent / guardian) consent to the taking of all radiographs.