Adult Medical History form

To ensure we have all the information we need for your first visit, please fill out the appropriate health history form below. 

Fields marked * are required.

Patient Details:

1st Responsible Party Details

Emergency contact details

2nd Responsible Party Details

Health History

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Privacy notice – Orthodontic patients

SMILE PARTNERS (ALBURY) PTY LTD (Evolve Orthodontics) collects personal and health information about you, from you directly and from other sources such as other health practitioners involved in your relevant care and treatment, to provide you with Orthodontic services and treatment. If you do not provide, or Evolve Orthodontics cannot otherwise collect all the information we request or need, Evolve Orthodontics may not be able to provide you with the requested services and/or treatments.

We may also use your information to manage and operate our practice, including to improve our services and treatment.

Sharing your personal information

Evolve Orthodontics may share your personal information with third parties as reasonably necessary to provide you with Orthodontic services or treatment, including other health practitioners involved in your care, Medicare and your health fund, or where we engage third party service providers in relation to the management or operation of our practice.

From time to time, we may also seek to use and share your information and images for research and education purposes. Unless you provide your consent below, we will not use or share identified information or images for this purpose.

We will always ensure that confidentiality is maintained over any of your information that we do share with other entities.

Direct marketing

With your consent, we may use your contact details to send you (by telephone, post, email or SMS) marketing communications to let you know about products, services, offers and events. You can opt out of marketing communications at any time, by following the unsubscribe function in the message we send or emailing us at

Social Media

From time to time, Evolve Orthodontics uses patient photographs and/or video (the Media) to promote its services and treatment, including through social media (eg Facebook, Google, Instagram). Unless you consent to such use below, we will not use images of you for marketing or promotional purposes.

I understand Evolve Orthodontics wishes to use (the Media) for the purpose of promoting the Company's services or for education purposes (the Purpose). I confirm that:

    1. The Patient grants the Company permission to use the Media or any part thereof, for use in any marketing activity for the Purpose.

    2. The Patient does not object to the Company storing copies of the Media for the Purpose.

    3. Use of the Media can be used in the production’s original format or edited or altered in any way which the Company deems appropriate.

    4. Use of the Patient’s name and likeness can be used for the purpose of marketing.

    5. The Company has the right to combine or edit the Patient’s likeness together with others.

    6. The Company owns all rights, title and interest (including all intellectual property rights) in the Media and any works derived from it.

    7. There will be no restrictions on:
    a) the number of times that Patient’s name and likeness may be used; and
    b) the geographical distribution of the Media.

    8. The Media is original and does not infringe anyone else’s rights and the Patient is authorised to grant the permission as set out in this consent form.

    9. The Patient waives any rights to inspect or approve the finished product, including audio or written copy that may be created in connection with the Media, or the use to which it may be applied.

    10. The Patient acknowledges that the production of the photographs and/or video was conducted in a proper and professional manner, and this release is willingly signed.

    11. The Patient acknowledges that no claims will be made by the Patient or anyone else for fees, compensation or royalties.

    12. The Patient releases Smile Partners (Albury) Pty Ltd trading as Evolve Orthodontics from any claims that the Patient may have against it, but for this consent.

    13. The Patient understands that Smile Partners (Albury) Pty Ltd trading as Evolve Orthodontics will treat all personal information in accordance with its Privacy Policy, which is available at

Further information

Our privacy policy, which is available includes our contact details, explains more about the types of personal information we usually collect and how we handle your personal information, how you can seek access to and correction of your personal information, how to make a privacy complaint and how we deal with complaints.

Privacy Consent

I give consent to Smile Partners (Albury) Pty Ltd trading as Evolve Orthodontics collecting, sharing and using my/my child's personal and health information as described above.

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