Health information is gathered for treatment purposes only. This information enables the provision of optimal dental care and helps in avoiding compromise of the patients general medical health.
Note: So that this dental practice can provide the highest standard of care, please fill in this form carefully and throughly.
Title Mr. Mrs Ms Other
Date Of Birth:
Postal Address(If different to above)
Name of person responsible for fees:
Address (If different to above)
Where did you hear about our practice?
---Google AdvertisingGoogle MapsFacebookInstagramTwitterReferralOther
Please enter the name of who referred you to our practice
Please enter your comment
Item number on your statement represent as accurately as possible the procedures performed, but in no way are they a claim on anyone other than the patient for whom they were performed. The eligibility of the patient, or the procedures, to attract refunds, and rates of those refunds, are determined by the conditions of the patient's Health Insurance Policy. We accept no responsibility, to either party, for any decision the insurer may make regarding the refund of monies to the patient
High Blood Pressure Yes No
Diabetes Yes No
Heart ailment Yes No
Thyroid problems Yes No
Rheumatic fever Yes No
Excessive bleeding or blood disorder Yes No
Asthma, Chest or breathing problems Yes No
Epilepsy Yes No
Tuberculosis Yes No
Hepatitis Yes No
Stomach or bowel problems (eg ulcer ) Yes No
AIDS/HIV Yes No
Kidney Disease Yes No
Bone Disorders or diseases Yes No
Do you smoke ?
How many ?
Would you like to stop ?
List any other previous illnesses
Would you like to discuss these questions in private with the dentist ?
Do you have artificial hip, heart valve or other prosthetic implant ?
Have you ever had problems with dental treatment ?
Are you presently under medical care ?
Are you taking any drugs, medicines or tablets ? (Please list)
Female patients, Are you pregnant ?
Do you have alergies?
List any medicines or products you are allergic to (e.g. Penicillin, Latex):
THANK YOU FOR YOUR ASSISTANCE IN COMPLETING THIS FORM AS FULLY AS POSSIBLE
I have read and understood the PRIVACY CONSENT DOCUMENT and consent to the collection and use of my health information.
ON FUTURE VISITS ANY CHANGES TO THE ABOVE SHOULD BE ADVISED. WORKING FOR THE COMMUNITY'S DENTAL HEALTH © ADAVB INC. 2004
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