New Patient Registration & Medical History Form

Welcome to The Myofunctional Centre.

For us to be able to look after you safely, please complete this form to the best of your knowledge.

If the patient is under 18 years old, a parent or an adult guardian is to fill in this form on behalf of the patient.

    Patient details



    If patient is under 18 years old

    Parent/Guardian 1

    Parent/Guardian 2

    Patient medical history








    Consent for Treatment and Cancellation Policy


    COVID-19 MESSAGE

    The Myofunctional Centre is a COVID Safe practice, following all the guidelines and regulations by the Victorian Government.