Have your details changed since your last visit?

Please answer the questions as completely as possible. It will assist us greatly in our effort to provide the best dental treatment for you and to safeguard your health and wellbeing.

Personal Details

Title*
First Name*
Last Name*
Preferred Name
Date of Birth*
Home Address:*
Suburb:*
Postcode:*
Phone (Mobile):*
Phone (Home):
Phone (Work):
Email*
Your Occupation:
How did you hear about us?
Emergency Contact Details
Emergency contact Name:*
Relationship to patient:*
Contact No:*

Health Fund
Health Fund Details:
Membership No.
Patient Id:
Medicare
Medicare Card No.*
Patient Id:
Vet Affairs Card No.
Medical Practitioner
To ensure our treatment is compatible with your present state of health, please answer the following:
I have confidential medical information I do not wish to write down. I would prefer to speak to the dentist about this
- YES Are you, at present, receiving medical treatment?
Doctors Name?*
Practice Address:*
Practice Phone:*

Medical Questionnaire- private and confidential

Please answer these questions fully or discuss them with your dentist. Information about your medical history is for your dentist’s use only

Are you currently pregnant or breastfeeding?
- Yes
- No
Due Date:
What is your smoking status?
- Non-smoker
- Ex-smoker
- Current smoker
How many per day?
Current medication (prescription, over the counter, herbal)

Please indicate if you have EVER had any of the following:

Please list:*

Any other relevant medical information? Please state

I further acknowledge that failure to attend any appointment without 24 hour’s notice will result in a NON-REFUNDABLE $30 CANCELLATION FEE, and I will need to deposit up to $100 prior to future appointments being scheduled. I have read and agree with the privacy statement provided to me.

Signature (Patient / Parent / Guardian)*

Date*

Have your details changed since your last visit?

Personal Details

Emergency Contact Details

Health Fund

Medicare

Medical Practitioner

Medical Questionnaire- private and confidential

RECENT BLOG POSTS

Quick Links

Follow us
on Social Media

Have your details changed since your last visit?

Personal Details

Emergency Contact Details

Health Fund

Medicare

Medical Practitioner

Medical Questionnaire- private and confidential

RECENT BLOG POSTS

Quick Links

Follow us on Social Media

Follow us
on Social Media