Preferred title: DOB:
First name: Last name: Preferred name: Address:
Suburb: Pcode:
Phone number: Email:
Parent/Guardian name: Carer name: Phone number:
Name: Phone number:
SelfOther Name: Address: Phone number:
Do you have private health insurance? YesNo
Hospital Fund: Dental Fund:
Policy number:
Are you eligible for the Child Dental Benefits Schedule? YesNo
Medicare card number: Ref. #
Is this consultation related to Workcover, a work-related injury or transport accident? YesNo
We collect the information set out above in order to provide you with dental services. We will keep your information secure and confidential. If necessary, we may pass your information on to other health practitioners for a second opinion or referral purposes. We may also be required by law to provide your information to outside agencies. Our complete Privacy Policy is available at reception.
Would you like to receive an appointment reminder? YesNo EmailSMSPhoneMail
Would you like to receive newsletters and notification of special offers? YesNo EmailSMSPhoneMail
To the best of your knowledge do you have or have you suffered from the following? If possible please provide approximate date of diagnosis.
NoneStrokeHigh blood pressureArthritisHeart diseaseAnxietyDigestive problemsAsthmaOsteoporosisRespiratory lung diseaseDiabetesInfectious diseasesHIV/AidsPacemakerBack or neck problemsCancerNeurological / nerve problems
Cancer, if so where:
Are you pregnant? If so, how many weeks?
Please state any major surgery you have had in the last five years:
Do you/have you received treatment for jaw related problems?
Do you smoke? YesNo If yes, how many per day?
Do you drink alcohol regularly? YesNo
Any other relevant medical history?
Do you have any allergies? YesNo
Do you have any adverse reactions to drugs? YesNo
If yes, please state allergy/reaction:
Emergency Plan:
There are many medications that may impact upon your oral health or the treatment we plan for you. Please indicate any medications that you are currently taking or have taken recently, including natural therapies. Alternatively, a list from your GP can be attached.
Current medicines / natural therapies:
Upload GP medication list, if applicable:
I agree to be responsible for all payment of fees and understand that payment is due at the time of the service.
Are you of Aboriginal or Torres Strait Islander origin? YesNo
Do you have a disability? YesNo
Do you identify as coming from a diverse background? YesNo
Signature / Full name: Date:
