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New patient Medical and dental history

To download the printable form click here.

 

Patient details
Title: Other:
Surname: Given name: D.O.B:
Residential address:
Suburb: State: Postcode:
Postal address (if different):
Home phone: Work phone: Mobile:
Email:*

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.

Occupation: Company:
Emergency contact: Phone: Relation:
Private health insurer: Member #: Patient #:
Vets Affairs #: Expiry:
GP name: GP phone:
GP address:
Preferred method of communication
Medical history

Have there been any changes to the following? If so, please tick the appropriate boxes.

Blood disorder name:

Have you ever smoked?
Approx. date if you have quit:
If yes, have you ever required treatment for smoking related diseases or conditions
Are you pregnant?
If so, due date?:
Any new allergies? If so, please list:
Are you taking medication (including natural supplements)? If so, please list:

Allergies

Other (please specify):
Dental history
Last dental visit:
Is there a particular reason for your visit today?:
Have you ever had a reaction or complication following dental treatment in the past?
If yes, please detail:
Is there anything else the dentist should be aware of?:

Are you suffering from any of the following?

Have you ever had a sleep study and been diagnosed with sleep apnoea?
If yes, have you ever tried Continuous Positive Airway Pressure (CPAP) therapy?
Has anyone ever told you that you snore?
After 6-7 hours of sleep do you wake up refreshed?

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?

Privacy policy

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.

How did you hear about us?
Referral Source:    
Keep Informed Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
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Consent for Services

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.

 

Any surgical or invasive procedure carries risks. Before proceeding with a surgical or invasive procedure, you should seek a second opinion from an appropriately qualified health practitioner.