New Patient Medical & Dental History Form
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 will
remain 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 Implant
Heart Disorder / Excessive Bleeding / Cardiac Pacemaker
Asthma / Stroke / Stomach Conditions
Steroid Therapy / Cancer / Hepatitis
Radiation Therapy / Tuberculosis / Lung Disease
Rheumatic Fever / Thyroid Disease / Blood Disease
Bone Disease / Nervous conditions / Allergy to Penicillin
Epilepsy / High or Low Blood Pressure / Allergy to Medication
Fainting Disorder / Sleep Apnoea / Allergy to Latex
If 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?
REFERRAL INFORMATION: Please Tick
Website / Walk Past
Brochure in mail / Google
Yellow Pages / Leader
Patient (please provide name so we can thank them):
Other :
DENTAL HISTORY:
Are you interested in or experiencing any of the following dental problems? Please tick
Sensitivity / Food trapping in teeth / Clicking/ pain in jaw
Staining of your teeth / Discoloured fillings / Bad Breathe
Bleeding Gums / Grinding/Clenching / Whitening
Straighten Teeth / Crowns / Veneers
What 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:______
1