New Patient Medical & Dental History Form

It is important to know details about your medical history as these could affect the success of your dental treatment and how we can provide this treatment safely for you. Please not that all information on this form willremain strictly confidential. Please ensure you fill out all questions.

PATIENT DETAILS: Title Mr./ Mrs./Miss./Ms./Master/(other)Name:Occupation: Date of

Birth:Phone Home: Home

Address:Phone Work:Phone Mobile:Email Address:Health Fund: Member Number:Emergency Contact:

Name:

Phone Number:Relationship:

MEDICAL HISTORY:Doctors Name: Doctors Number:Have you ever had or are you suffering from any of the following? Please Tick Diabetes Kidney Disease Prosthetic ImplantHeart Disorder Excessive Bleeding Cardiac PacemakerAsthma Stroke Stomach ConditionsSteroid Therapy Cancer HepatitisRadiation Therapy Tuberculosis Lung DiseaseRheumatic Fever Thyroid Disease Blood DiseaseBone Disease Nervous conditions Allergy to PenicillinEpilepsy High or Low Blood Pressure Allergy to MedicationFainting Disorder Sleep Apnoea Allergy to LatexIf yes to any of the above please provide more information

Any other conditions not mentioned?Are you Pregnant?If Yes how many months?Are you taking any medication? If yes please specify.Do you smoke? How often do you

drink alcohol?

1

REFERRAL INFORMATION: Please Tick Website Walk PastBrochure in mail GoogleYellow Pages LeaderPatient (please provide name so we can thank them):Other :

DENTAL HISTORY:Are you interested in or experiencing any of the following dental problems? Please tickSensitivity Food trapping in teeth Clicking/ pain in jaw Staining of your teeth Discoloured fillings Bad BreatheBleeding Gums Grinding/Clenching WhiteningStraighten Teeth Crowns VeneersWhat is the main purpose of your visit today?

How long since your last dental?Does dental treatment make you nervous?

CONSENT FOR SERVICE: I consent to the performing of dental and oral surgery procedures agreed to

be necessary to advisable, including the use of local anaesthetic and other medication as indicated and i will assume responsibility for the fees associated with the procedure.

I understand that the practice requires 48 hours notice if i need to change my appointment and that cancellation fees may apply if I fail to do so.

I hereby authorise the dentist or the designated team to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.

I am aware that payment is required on the day of treatment and that American Express is not accepted.

We provide a courtesy to our patients, a preventative care program that offers a SMS service is if have not been to the practice in 6 months.

Patient/Parent/Responsible person name:________________________________________

Signature:_________________________________________________________________

Date:____________________________

2