Update your details Your details Preferred contact phone: Home phoneBusiness phoneMobile phone Do you have Private Health Cover for Dental: YesNo Confidential Medical History Are you or have you ever been treated for any of the following? Rheumatic FeverDiabetes Type 1/2Blood DisorderHIV/Hepatitis A B CKidney disease AsthmaNervous DisordersEpilepsyMalariaAngina A strokeHigh/Low Blood PressureHigh/Low CholesterolCancer - enter year: Do you smoke? YesNo If yes, how many per day? 5102030 Do you have any drug allergies? YesNo Latex allergy? YesNo Are you currently taking any medications? YesNo Are you currently receiving any medical treatment? YesNo Have you had an unfavourable reaction to local anaesthetics? YesNo Ladies, is there a possibility that you are pregnant? YesNo We request and expect payment at the time of treatment. For your convenience Design Dental Group is equipped with the "HICAPS" system and accept cash, cheques, eftpos, and most major credit cards.