Patient History Form

It’s essential South East Orthodontics know the details of your medical history. Having our patient’s medical history enables our dentists to obtain the necessary information to provide safe and individualised care.

Please note, all the information you give us on this patient history form will remain strictly confidential.

Please fill out the form below, or click to download and print it.

If you have any questions please don’t hesitate to call us and speak to our friendly staff.

  • Patient details

  • If you answer “Yes” to any question 11-24 please provide details in the space provided

  • This field is for validation purposes and should be left unchanged.

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  • Find Us
    2/31 Clyde Rd, Berwick VIC 3806
  • Phone
    03 9796 2794
  • Fax
    03 9796 1759
  • Email
    info@seortho.com.au
  • Opening Hours
    Mon - Fri 8:30am - 5:30pm

Glen Iris Treatment Room

1564 Malvern Road,
Glen Iris VIC 3146

Available for all treatments with Dr Kip Homewood once every month on a Wednesday from 1.30pm to 6.30pm. Please contact our Berwick practice to make an appointment or enquiry.

Invisalign offers a discreet and effective way to straighten your teeth. If you are looking for more information about how Invisalign can help to improve your smile, download our free guide!
invisalign guide
Get Your Free Invisalign Guide!
Early intervention often takes advantage of the fact that your child’s jaw is still growing and can reduce the likelihood of future definitive orthodontic treatment with braces, to learn more download our free children's orthodontics guide!
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Get Your Free Children's Orthodontics Guide!