Medical History Form

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Title Mr. Ms Miss

*Date of Birth / /

*First Name

*Surname

Home phone no.

*Mobile phone no.

*Address

*Suburb

*Post Code

E-mail Address

Occupation

*Emergency Contact Name

*Emergency home/mobile phone no.

Do you have PRIVATE HEALTH INSURANCE?
YES NO

Name of your regular medical practitioner (GP)

Do you have any other important health issues?

Do you snore, Or does your partner say you do?

Do you feel you need to sleep better?

SERVICE IMPROVEMENTS:

Do you require any support for your (options) back/ leg/ neck lying back?

What kind of music helps you feel relaxed (genre/artist/album)?

How else can we help you feel more comfortable during your visit?

PATIENT DECLARATION:

I declare that I have completed this form to the best of my knowledge, and that the information provided is an accurate medical history of the above mentioned patient. On future visits, I will advise the dentist of any changes to the history.

*If I am unable to attend future appointments, I will give 48 hours notice to this practice via phone or email. Otherwise, I acknowledge that failure to give 48 hr notice will incur an administration fee.
I understand and agree that payment is due and will be made at the time of my appointment.

*Signature (please click the box below to sign your signature)

Date / /

Parent/Guardian if under 18 years

Medical History Form

DENTAL & MEDICAL HISTORY :

Please tick the box and input details, if any of the following applies. When you are not sure about the answer, please tick the box and type "unsure" or specify your concerns.

Have you had or do you have any of the following?

MEDICAL CONDITIONS:

SERVICE IMPROVEMENTS:

PATIENT DECLARATION: