Patient details

First Name *

Last Name *

Email *

Phone *

Date of birth *

What is your gender? *

Address

Street Address *

City *

State *

Postal Code *

Occupation *

Medicare Number

Private Health Insurer *

IRN

Emergency Contact *

Emergency Contact Phone *

Relation *

GP Name *

GP Address

GP Phone

Medical history

Medical Conditions (can add multiple)

Current Medications (If have any)

Do you have any Allergies *

Yes

Smoking Status *

Are you pregnant *

Drinks Alcohol *

Dental history

Last Dental Visit *

Previous Dental ReactionHave you ever had a reaction or complication following dental treatment in the past? *

Yes

Do you have any private or confidential information you wish to discuss in private and not write down? *

Yes

Additional informatoin

Are you suffering from any of the following? *

How Did You Find Us *

Anything else you would like to tell us?

Any information is collected and maintained in accordance with State and Federal Privacy Legislation.

I have accurately completed this medical history form to the best of my knowledge. I hereby give my authority for any treatment agreed upon by me to be carried out by the dentists and their staff. 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 my dentist to take images of my teeth both before and after my treatment. I understand these images may be used in a practice portfolio to showcase examples of dental work to other patients, and my identity will remain anonymous.

Date *

Patient Signature *

Clear