Dentists of Ivanhoe

PATIENT HISTORY FORM

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.

    Medical Questions- Private and Confidential

    Please take care to fill out this form completely. We rely on all your information to be able to provide you with appropriate dental services. Privacy Policy- 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.

    Past/Current medical conditions: (please tick)

    YesNo
    /day

    Please indicate if you have EVER had/have any of the following: (Please Tick)

    Please indicate if you have EVER had/have any of the following: (Please Tick)

    YesNo

    Would you like to discuss or find out more about any of the following: (please tick)

    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