Orthodontic Practice in Remuera and Ormiston Auckland

ortho@remuera

Unit 5,
81A Remuera Road,Newmarket,
Auckland, 1050.
P. 09524 9231 or 0800 BRACES
E: remuera.reception@Ortho1.co.nz

ortho@ormiston

Level 2, Ormiston Hospital,
125 Ormiston Road, Flatbush,
Manukau City 2016.
P. 092774989 or 0800 BRACES
E: ormiston.reception@Ortho1.co.nz

Health Practitioner Referral Form
If you would like to make a referral for a CBCT scan for a patient, please complete the form below:

33%

MEDICAL HISTORY QUESTIONNAIRE
Are you being treated for anything now and if so what?
Do you have any allergies?
Do you carry a special health card or bracelet?
Do you have any of the following problems?
Heart problems?*
- Yes
- No
Rheumatic Fever?*
- Yes
- No
Diabetes?*
- Yes
- No
Fits or Epilepsy?*
- Yes
- No
Asthma?*
- Yes
- No
Are you taking any medication for any of the above problems? If so please please list them here:
Have you ever had any bleeding problems?*
- Yes
- No
If yes, please give details
Have you any reason to believe that you may be at risk of any infectious or other diseases?
- Yes
- No
If yes, please give details
The medical history I have given is true and correct to the best of my knowledge*
- Yes