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

    MRMASTERMRSMISSMSDR
    NoYes


    Least 12345678910    Most
    Please note that our policy is to receive payment on the day of your treatment. We accept cash, eftpos, visa, mastercard and american express.
    YesNo
    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.
    YesNo
    Who recommended our practice to you?
    Existing patient
    DoctorStaff MemberDentistYellow Pages/sensisBeachside Dental WebsitePassing byGoogle searchCall ConnectFacebookLeader NewspaperSmooth FM Radio

    MEDICAL HISTORY QUESTIONNAIRE

    Please Tick Questions 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

    YesNo

    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*.