Patient Information

Title*

Miss

Mrs

Others

Surname*

Given name*

Preferred Name

DOB*

Home Address*

Postal Address

Same As Above

Other

Primary Phone / Mobile*

Alternative

Email*

Ocupation

Parent Guardian Name

If applicable

Phone

Person responsible for the fees?

Person responsible for the fees?*

Self

Parent/Guardian

Others

Other

Health Fund Details

Health Insurance Fund (if you have dental cover)

Are you eligible for the Child Dental Benefits Schedule (CDBS)?

Yes

If Yes, Medicare Card Number

Ref No.

Department of Veterans Affairs Card Number

If applicable

Emergency Contact

Emergency Contact Name*

Phone*

Relationship to You*

General Practitioner

Medical Doctor Name*

Phone

Address

How did you hear about us?

Medical History

Have you had any of the following?

Heart problems*

Yes

Arthritis*

Yes

Asthma*

Yes

Circulatory problems*

Yes

Osteoporosis*

Yes

Respiratory issues*

Yes

Rheumatic Fever*

Yes

Joint surgery*

Yes

Epilepsy*

Yes

High Blood Pressure*

Yes

Bone disorders*

Yes

Neurological (nerve) issues*

Yes

Excessive Bleeding*

Yes

Back/neck problems*

Yes

Anxiety*

Yes

Pacemaker*

Yes

Stomach Ulcers*

Yes

Tumours / Cancer*

Yes

Stroke*

Yes

Gastric Reflux*

Yes

Radiotherapy / Chemo*

Yes

Thyroid issues*

Yes

Liver issues*

Yes

Hepatitis A/B/C/D/E*

Yes

Diabetes*

Yes

Sinus issues*

Yes

HIV/Aids*

Yes

Kidney problems*

Yes

Do you have an artificial joint, heart valve or other prosthetic implant?*

Have you been under medical care or treatment in the last 12 months? (Please list)*

List any other previous or current illnesses/surgeries in the last 5 years*

Female patients, are you pregnant?

Yes

Due date

Do you smoke?*

Yes

How many per day?

Dental Oro/Facial Issues

Does your jaw joint click or hurt?*

Yes

Do you/have you received treatment for jaw related problems?*

Yes

Do you clench or grind your teeth?*

Yes

Do you wear a night guard/splint?*

Yes

Have you had periodontal (gum) treatment?*

Yes

Do your gums bleed when you brush your teeth?*

Yes

Do your teeth hurt biting into hard foods?*

Yes

Do you experience sensitivity to hot/cold/sweet*

Yes

Do you have a poor fitting denture?*

Yes

Have you ever had orthodontic treatment?*

Yes

Medications

Are there many medications that may impact upon your oral health or the treatment we plan for you. Please list any medications that you are currently taking or have taken recently (including natural therapies)

Medications 1.*

Medications 2.

Medications 3.

Medications 4.

Medications 5.

Medications 6.

Do you need antibiotic cover for dental treatment (eg: if you have had heart valve replacement)?*

Yes

Have you ever had any problems with dental treatment?*

Yes

If Yes, Please describe

Allergies and Adverse Reactions

Do you have any allergies/adverse reactions to anything?*

Are you happy with the appearance of your teeth?*

Yes

If not, what would you change?

How long has it been since your last dental visit?*

Is there anything else you would like to discuss with your Clinician in private?*

Yes

We send appointment reminders and recalls via Email and SMS. Do you agree to receiving these?*

Yes

Privacy and consent for treatment

1. I hereby authorise the dentist or designated staff to take x-rays, study models, photographs and other diagnostic aids deemed necessary by the dentist to make a thorough diagnosis. Under the Dental Act, all records are to be kept for seven years by the practice.

2. 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 proper care.

3. I agree to the use of anaesthetics and other medication necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand I can ask for a complete explanation of any possible complications.

4. I agree to the disclosure of my health information to other health care professionals or require it from them if it is beneficial in the context of my treatment. In that event, disclosure of my personal details will be minimised wherever possible. Our complete Privacy Policy is available at reception.

5. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependant/s. I understand payment is due on the day of service unless other arrangements have been made.

6. We appreciate the value of your time. Except in emergency situations you can expect us to be on time for you. We would appreciate the same courtesy. No charge will be made for rescheduling your appointment, provided 24 hours’ notice is given, so that time may be given to other patients.

If you fail to give us 24 hours notice or fail to attend your appointment, a fee of $40 per quarter hour will be charged.

You can otherwise be assured that your health information will be treated with the utmost confidentiality. Disclosure will not be made to any person not involved in either your treatment or the administration of this practice, without prior written consent. If you have any queries or concerns about our handling of your health information, please do not hesitate to raise these concerns with our practice.

Tick box below to confirm that you have read and agree to the above conditions for/on behalf of:

AGREE*
Yes

Patient’s Name*

Parent/guardian Name

Date*
DD dash MM dash YYYY