Medical History Form

Company

This field is for validation purposes and should be left unchanged.

Patient Information

Preferred Title

Mrs

Other

Full Name(Required)

Date of Birth

Address

Phone(Required)

Email(Required)

Emergency Contact (Name & Phone):(Required)

GP Clinic & Contact number

Medical History

Please tick if you have or have had:(Required)

Prosthetic joint/heart valve – if yes, specify:(Required)

Cancer (type)(Required)

Allergies (e.g., Penicillin, Latex)(Required)

Other (please specify)(Required)

Any recent surgery (if yes, please specify)(Required)

Do you smoke?

Yes

if yes, how many/day:(Required)

Are you Pregnant (if applicable)?

Yes

Weeks(Required)

Current Medications

Dental History

Reason for Visit Today(Required)

Last Dental Check-up(Required)

How Did You Find Us?(Required)

Privacy Statement

We collect your personal and medical information to provide safe and effective dental care. Your data will remain confidential and may only be shared with other healthcare providers if necessary for your treatment or as required by law.
We may also use secure and approved technologies to assist in diagnostics, treatment planning, and administrative support. These tools are used in accordance with applicable privacy laws and are designed to enhance the quality of your care.

I consent to the use of such technologies as part of my dental care.(Required)

I consent to the use of such technologies as part of my dental care.

Appointment & Cancellation Policy

• Notify us ASAP if you cannot attend. After-hours, leave voicemail.
• If late, appointment may be shortened.
• Less than 24h cancellation or no-show: $100 fee.

I understand payment is due on the day of treatment.(Required)

I understand payment is due on the day of treatment.

I acknowledge and accept the above policy.(Required)

I acknowledge and accept the above policy.

Patient/Guardian’s Name:(Required)

Signature(Required)

Date(Required)

Patient Information

Medical History

Dental History

Privacy Statement

Appointment & Cancellation Policy

About Us

Servicing Suburbs

Contact Us

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