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We will be closed from Monday 23rd December and will re-open on Monday 13th January 2025. Please email to drsmilestyle@gmail.com to make an appointment as our phone won’t be checked during this time. We wish you and your families a safe and Merry Christmas and a Happy New Year!

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Book A Consultation
Treatments
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Patient Information
Join Our Team

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Updated Patient Information

Updated Patient Information

If you have been a previous patient at our practice, please help us by completing the form with your updated information.

Patient's Personal details

Title*

Mr Mrs Miss M/s Dr Unspecified

First name*

Last name*

Sex*

Male Female Unspecified

Date of Birth*

Home Address*

Suburb*

Postcode*

Email*

Mobile phone*

Dental Information

Patient's Dental Practice Name*

Patient's Dentist Name*

Medical Information

Family Doctor*

Phone number*

Address of Doctor*

Patient's Medical and Dental History

Have you been double vaccinated to COVID-19?*

Yes No

Please check if you ever had any of the following

Asthma

Anemia

HIV Aids

Hepatitis

Epilepsy

Rheumatic Fever

Diabetes

Psychiatric Care

Head or Face Injury

Hormonal Disorder

Bone Disorder

Emotional Disorder

Bleeding Disorder

Blood Disease

Hearing disorder

Heart Disease

None of the above

What medications is the patient currently taking?*

Is the patient pregnant?*

Yes No

Does the patient smoke?*

Yes No

Any allergies?*

Yes No

If yes, what are the allergies?

Are there any other medical problems we should be aware of?*

Pain or clicking in the jaw joints?*

Yes No

Chewing and swallowing difficulty?*

Yes No

Grind their teeth?*

Yes No

Have a speech problem?*

Yes No

Have any teeth ever been injured due to an accident or having received a serious blow?*

Yes No

If yes, when?

When did the patient have their last Dental Check - Up?

Do you have any outstanding general dental work to be completed?

Person responsible for paying your accounts*

Myself Parent / Guardian

Full Name*

Occupation*

Employment Status*

Are you covered by private dental insurance?*

Yes No

Fund name*

Are you covered by the Medicare scheme?*

Yes No

Medicare Card Number*

Reference Number*

Medicare Expiry date (MM/YYYY)*

Are you an Australian citizen?*

Yes No

Title*

Mr Mrs Miss M/s

First name*

Surname*

Mobile number*

Relationship to Patient*

Billing Address*

Suburb*

Postcode*

Occupation*

Employment Status*

Are you an Australian citizen?*

Yes No

Are you covered by private dental insurance?*

Yes No

Fund name

Are you covered by the Medicare scheme?*

Yes No

Medicare Card Number*

Reference Number*

Medicare Expiry date (MM/YYYY)*

Do you have any other children in the family?*

Yes No

Name

Age

Name

Age

Name

Age

The Family Care Program

Orthodontic problems often run in families. As a courtesy to our patients, we are happy to offer a complimentary consultation to "other" family members.

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By submitting this form, you are agreeing to our privacy policy.

Why we’re the clear choice for your treatment

Trust the team at SmileStyle Orthodontics to deliver the smile results you want.

1.

1,000 happy smiles created with Invisalign®

We are your local Diamond Invisalign® providers.

2.

Two convenient locations and easy parking

Come visit us in Loganholme or Capalaba.

3.

Excellent results for the whole family

It’s never too late to achieve your dream smile.

4.

State-of-the-art technology

We use the latest equipment to bring you the best results.

5.

30 years of specialist experience

We can treat even complex orthodontic issues at our practice.

6.

No deposit, no interest payment options

We keep a straight smile attainable on any budget.

Meet Dr Tselepis Meet our team

Loganholme
Capalaba

70 Bryants Road Loganholme Queensland 4129 Australia

enquire@michaeltselepis.com

Monday - Friday: 8am - 5pm
Wednesday: Closed
Saturday: Closed
Sunday: Closed

Suite 4 76 Old Cleveland Rd Capalaba Queensland 4157 Australia

enquire@michaeltselepis.com

Wednesday only:: 8am - 5pm

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