To download the printable form click here.
We will send you email communications from time to time, including appointment reminders. Please tick this box if you do not wish to receive email communication from us.
Have there been any changes to the following? If so, please tick the appropriate boxes.
Allergies
Are you suffering from any of the following?
On a scale of 1 – 10, with 10 being very comfortable and not at all anxious, how comfortable are you feeling about your appointment today?
Any information is collected and maintained in accordance with State and Federal Privacy Legislation. A copy of our privacy policy can be obtained on request. I have accurately completed this medical history form to the best of my knowledge. I hereby give my authority for any treatment agreed upon by me, to be carried out by the dentists and their staff. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made. I authorise my dentist to take images of my teeth both before and after my treatment.
I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.