Penrith Dentists | Dental History Penrith | Need Patient History Penrith | Penrith Dentistry

02 4722 6299 enquiry@lethbridgedental.com.au
110 Lethbridge St, Penrith NSW 2750
MON – FRI : 8.30am to 6.00pm
SAT : 8.30am to 5.00pm

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Home
About Us
- Our Team
- Blog
Our Services
Smile Gallery
Patient Information
Promotions
Contact Us

4722 6299 | 4722 6966
110 Lethbridge St, Penrith
penrithdentistry.com.au

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:
- Any heart complaint / treatment
- Rheumatic fever or heart valve surgery
- High or low blood pressure
- Blood disorders
- Anti-coagulant therapy
- Joint replacement surgery
- Osteoporosis or bone disease
- Epilepsy
- Diabetes
- HIV or other blood borne viruses
- Steroid therapy
- Sinus trouble
- Stroke
- Tuberculosis
- Any nervous system disorder
- Gastric ulcer / digestive conditions
- Asthma/ bronchitis / lung conditions
- Radiation therapy / chemotherapy
- Thyroid disease
- Hepatitis A, B or C
- Jaundice or other liver diseases
- Transplanted organ or bone marrow
- Arthritis
- Depression / anxiety
- Kidney disease
- Bisphosphonate medications
- Allergy to Latex
- Allergies to any other medications
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*

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