Please fill out all the necessary information on this form and click on SUBMIT FORM at the bottom of the page; when you sign the bottom of this page you agree that you are happy for your information to be used by any dentist/staff member in accordance with your treatment.

Title

First name

Surname

D.O.B.

Mobile

Phone

Address:

Suburb:

Postcode

Email :

Please tick box if you do not wish to receive promotions

Emergency/secondary contact name and number (Please provide Guardian if under 18):

Do you have private insurance with dental cover, if so which fund?

Please Provide your membership number:

Member Reference number:

When was your last dental visit and x-rays?

Have you ever had cosmetic procedures such as wrinkle treatments or dermal fillers?

Do you have allergies to any drugs, medicines or latex?YesNo

If yes

Please state ALL medications you are currently taking including bisphosphonates or blood thinners:

Do you or have you ever suffered from any of the following? If so, please elaborate in the space provided.

RHEUMATIC FEVERYesNo

HEART PROBLEMSYesNo

ANAEMIAYesNo

TUBERCULOSISYesNo

HEART VALVE (PROSTHETIC)YesNo

DIABETESYesNo

TUMOUR HISTORYYesNo

CARDIAC PACEMAKERYesNo

ARTHRITISYesNo

CHEMOTHERAPYYesNo

HEPATITIS A, B OR CYesNo

ASTHMAYesNo

RADIATION THERAPYYesNo

HIV/AIDSYesNo

EPILEPSY YesNo

HIGH BLOOD PRESSURE YesNo

KIDNEY DISEASE YesNo

SINUS PROBLEMSYesNo

LIVER DISEASEYesNo

BLEEDING DISORDERSYesNo

OSTEOPOROSISYesNo

SMOKERYesNo

FITS OR SEIZURESYesNo

PROSTHETIC JOINTSYesNo

PREGNANT YesNo

OTHER MAJOR SURGERY OR CONDITIONS:

Date