Welcome, so that we may provide you with the best possible care please complete all fields of this medical history form. All information is completely confidential. No information is stored on this site for security purposes.

If you prefer to download and print the form, please download it here.

PATIENT INFORMATION

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Please note that our policy is to receive payment on the day of your treatment. We accept cash, eftpos, visa, mastercard and american express.
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Cancellations: 48 hrs notice of any cancellation is kindly required or a cancellation fee may be charged.
Patients who have dental insurance: Item numbers are used as accurately as possible to describe the treatment received but cannot be claimed for anyone other than the person who received the treatment. The rebate is determined by your individual health insurance policy. Our surgery is not responsible for any concerns you may have regarding your health fund.
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Who recommended our practice to you?
Existing patient
DoctorStaff MemberDentistYellow Pages/sensisBeachside Dental WebsitePassing byGoogle searchCall ConnectFacebookLeader NewspaperSmooth FM Radio

MEDICAL HISTORY QUESTIONNAIRE

Please TickQuestions DETAILS
NoYes High Blood Pressure
NoYes Low Blood Pressure
NoYes Heart Ailment or Heart Murmur
NoYes Congenital heart Problem
NoYes Heart Valve/Pin/Stent
NoYes Pacemaker
NoYes Rheumatic Fever
NoYes Bleeding Disorder
NoYes Diabetes
NoYes Liver or Kidney Disease
NoYes Hepatitis A / B / C / D / E
NoYes HIV / AIDS
NoYes Asthma
NoYes Epilepsy
NoYes Cancer
NoYes Chemotherapy
NoYes Bone Disease / Disorder
NoYes Tuberculosis
NoYes Hormone Supplements
NoYes Knee / Hip / Joint Replacement
NoYes Ladies, are you pregnant?
Are you currently under any medical care? NoYes
Are you allergic to Penicillin? NoYesMaybe
Are you allergic to latex? NoYesMaybe
Have you ever reacted badly to medication? NoYes
Have you ever reacted badly to Dental Treatment? NoYes

DENTAL HISTORY

Do you smoke? NoYes
Does your jaw click or hurt? NoYes
Have your teeth chipped or worn down? NoYes
Do you grind your teeth? NoYes
Does food get stuck between your teeth? NoYes
Have you had previous gum problems? NoYes
Do your gums bleed when you clean your teeth? NoYes
Do you suffer from bad breath? NoYes

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Please tick this box to confirm that you have read and understood our Privacy Policy, and consent to use of your health information in this way
Yes, I've read the Privacy Policy*.