New Patient Medical History Form

Patient’s details

Appointment date

Title: Mr / Mrs / Ms / Miss / Dr

First Name

Last Name:

Preferred as:

Phone. Home

Phone. Work

Phone. Mobile

Email

Date of Birth

Age

Occupation

Address

#:

Street:

Suburb:

State:

Post Code:

Emergency contact

Name

Relationship

Phone number

Dentist / Referral

Dentist name:

Practice name:

Phone (Practice):

Tooth # Area to be treated

Referred by:

Dentist

Self-referred

Doctor / Medical History

GP Name:

Practice Name:

GP’s Phone No

GP’s address (or suburb)

Have you ever been diagnosed with any of the following conditions:(Add any relevant comments)

Please list the medications currently being taken:

CAUTION - Have you ever taken any of the following medications?

ALLERGIES - Are you allergic to any of the following? (include any adverse reactions)

Are you pregnant?

No

Yes

in the

1st trimester

2nd trimester

3rd trimester

Are you nursing?

No

Yes

Smoking cigarettes:

Yes

No

Ex-smoker

Year quit:

Average cigarettes per day

Years smoked

Alcohol intake:

Yes

No

how many standard drinks per week?

Dental attendance frequency:

Regular

Only when there is a problem

Hospitalisation in the last 2 years:

No

Yes

Nervous about dental treatment:

No

Slightly

Moderately

Extremely

Previous sedation for dental treatment:

Are you of Aboriginal or Torres Strait Islander origin?

No

YesYes

Were you born in a country other than Australia?

No

Yes

Were you born in a country other than Australia?’, which country?

What is your preferred language?

English

OtherOther

CONSENT FOR SERVICES

I accept responsibility for all fees associated with consultations, procedures, and reviews and understand that full payment is required on the day of each visit.

I acknowledge that there may be health insurance policies determining the eligibility for rebates and level of coverage, and that

I am responsible for obtaining this information independently.

I understand that the practice requires a minimum of 48 hours’ notice for cancellation or rescheduling of an appointment

I acknowledge that a cancellation fee of $200 may be incurred if this notice is not provided.

I consent to the use of my radiographs, clinical photographs, and digital images being shared with other dental practitioners to assist in my care.

I also consent to their use, in de-identified form where appropriate, for educational purposes including dental or endodontic seminars, lectures, and professional publications.

I confirm that I have completed this questionnaire to the best of my knowledge and understand that failure to disclose relevant medical information may place me at increased medical risk.

Patient/Guardian

Signature

Clear

Date

Please use the form below to submit your medical history.

Alternatively, download our referral form to the left and fill out and bring it with you.

Medical History Form