TitleDr Mr Mrs Ms Miss
Please select the preferred contact number above
Do you have Private Health Insurance that covers: Dental Y N Private Hospital Y N
How did you find out about our practice? Family Member Friend / Associate
Driving past / saw signage Local Directory Yellow Pages Google Website Radio Other:
Have you ever had your teeth cleaned by a hygienist? Y N
Have you had your wisdom teeth removed?Y N
Have you ever had gum disease or bleeding gums? Y N
Have you ever had braces or any other orthodontic treatments? Y N
Do you wear a night guard? Y N
Do you clench/grind your teeth? Y N
Are your teeth sensitive to hot/cold? Y N
Does floss tear in between or food get caught in your teeth?Y N
When was your last dental appointment? < 12 months 1-2 years other
When were dental x-rays last taken? Less than a year ago Longer than a year ago
Heart problems Y N
Blood pressure Y N
Circulatory problems Y N
Anaemia Y N
Blood / immune disorders Y N
Excessive bleeding Y N
Excessive bruising Y N
Latex allergy Y N
Rheumatic fever Y N
Artificial joints Y N
Osteoporosis Y N
Cancer history Y N
Radiation treatment Y N
Hepatitis A B C D E Y N
Liver problems Y N
Penicillin allergy Y N
Kidney problems Y N
Epilepsy Y N
Diabetes Y N
Sinus trouble Y N
Asthma Y N
Ulcers (stomach) Y N
Reflux Y N
Other allergies Y N
If yes, please specify:
Are you on any medications?Y N If yes, please list below:
Do you carry any emergency medications with you?Y N If yes, please list below:
Any hospitalisations in the past 2 years? Y N If yes, please list below:
Any other medical conditions not listed above? Y N If yes, please list below:
Do you currently smoke? Y N
Are you pregnant? (Women only)Y N If yes, what is your due date?
Are you under the care of a GP? Y N
Are you under the care of a Specialist? Y N
By submitting this form, I hereby authorise the dentist or designated team to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide appropriate care. I agree to the use of anesthetics’, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand I can ask for a complete recital of any possible complications. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made. I authorise that this data may be reviewed by team members of the dental practice.
