MEDICAL HISTORY FORM

It is important to know details about your medical history as this could affect your oral health care.
Please know that your confidentiality is our highest priority and this information will be handled in accordance with our privacy policy. Please ensure both pages of this form are completed.

Gender
Male / Female

Date Of Birth
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Surname

First Name (s)

Preferred Name

Home Address

Suburb

Post Code

Home Phone

Mobile Phone

Work Phone

Occupation

Contact in case of emergency (Name)

(TEL)

Email Address

I do not wish to receive email newsletters

Person responsible for fees (if not self)

Your Current General Practitioner and Suburb

I have confidential medical information that I do not wish to write down.
I would prefer to speak to a dentist about this. ( Please tick appropriate box )

How long since you’ve consulted a dentist

Have you ever had any difficulty with Tooth Extractions

Have you had any Serious Illnesses or Operations

Are you currently taking Medications ( please list )

Are you Allergic to any Medications ( include Latex )

Are you allergic to any anesthetics ( Local or General )

Would you like a Reminder for your appointment s YES NO

Preferred method of contact Call Fax Email Text Message ( SMS )

Is another member of your family a patient at our office

Is there anything else you would like us to know

I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, that may be associated with general preventive and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit. I acknowledge that the nature and purpose of the forgoing procedures will been explained to me and if necessary and that I will been given the opportunity to ask questions before treatment commencement.

Patient’s Signature

Your Signature:

Date / /

Parent / Responsible Party’s signature

Relationship to Patient

I agree to settle my account in full today. Everyday Smile Dental Practice is not responsible for the rebate negotiations between you and your healthfund. Regardless of the healthfund rebate Everyday Smile Dental Practice expects and appreciates all patients to settle their account in full at the completion of each appointment.

We accept all major credit cards (excluding Diners Club), Personal Cheque, Eftpos and Cash.
We also provide service for direct private health fund claims .

Please know our surgery sincerely values you, your family and your time. Although we do make every effort to keep our schedule, as a medical faculty, emergencies can arise.

Please ask our receptionist if she can be of assistance in any way, or if you have any queries regarding our privacy policy.

We always welcome your referrals!

Date / /