Medical History

To assist in determining your treatment, please answer the following questions as accurately as possible.

Please read through and accept our Privacy Policy, when accepted please continue to the next page.

Privacy Policy

In accordance with the Victorian Health Records Act 2001 and the Federal Privacy Act 1988

Our practice respects your right to privacy. We realise that it is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our practice and to whom this information might to disclosed.

The policy of our practice as recommended by the Australian Dental Association is to follows these procedures:

The information collected will be used for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of addressing account to you, as well as processing payments and writing to you about our services and any issues affecting your treatment.
We may disclose your health information to other healthcare professionals, or require it from them if, in our judgment, that is necessary in the context of your treatment. In that event, disclosure of your personal details will be minimised wherever possible.
We may also use parts of your health information for research purposes, in study groups or at seminars as this may provide benefit to other patients. Should that happen, your personal identity will not be disclosed without your consent to do so.
Your medical history, treatment records, x-rays and any other material relevant to your treatment will be kept here. You may inspect or request copies of our records or your treatment at any time, or seek an explanation from the dentist. Statutory fees will apply in relation to the types of access that you seek. If you request an explanation of our records or a written summary, our usual fees apply to these services.
If any of the information we have about you is inaccurate, you may ask to alter our records accordingly.

You can otherwise rest assured that your health information will be treated with the utmost confidentiality. Disclosure will not be made to any person not involved in either your treatment or the administration of this practice, without prior written consent. If you have any queries or concerns about our handling of your health information, please do not hesitate to raise these concerns with our practice.

Please accept the above policy by ticking the box below. *

Patient Information

First Name *

Last Name *

Date of Birth *

Mobile Number *

Home Number

Work Number

Email Address *

Occupation *

Address *

Referral Information

Your General Dentist *

General Dentist Phone Number

How long have you been a patient?Estimate in years

Who referred you to this office? *

Emergyncy Contact

Emergency Contact Name *

Emergency Contact Phone Number *

Medical Information

Your general health constitutes an important factor, and in combination with the other causes, may influence the course of periodontal disease. To assure your health during therapy and to assist in establishing a thorough diagnosis for successful treatment, please complete this confidential form.

Do you have a medical condition that requires ANTIBIOTIC COVER prior to dental treatment? *

YesNo

Have you ever taken a medication to manage osteoporosis? (i.e bisphosphonates)? *

Yes, CurrentlyNo, but have in the pastNo

Are you a smoker?

NeverPastCurrent

Cigarettes Per Day?

How many years?

When did you quit?

Diabetes *

YesNo

Diabetes type?

Type 1Type 2

What was the result of your most recent blood sugar test (HbA1c)?

Pregnant

YesNo

When is your due date?

Other Allergies

Are you currently taking any drugs or medication? *

YesNo

Please list all drugs and medication here?Separate with ;

Other Procedures

Which joint or valve and when was it performed?

Has your Orthopaedic Surgeon advised you to take antibiotics before receiving dental treatment?

Who is your current medical doctor?

Are you currently under the care of any Medical Specialist?

YesNo

Provide Medical Specialists Name(s)

Specialist(s) Phone Number(s)

Please tick relevant Medical Specialist(s):

CardiologistEndocrinologistOrthopaedic SurgeonOther

Other:

When were your teeth last “cleaned” by a dentist or dental hygienist?Estimate Only, leave blank for Never.

How frequently have your teeth been “cleaned’ by a dentist or dental hygienist in the last 5 years?

Confirmation

DECLARATION

I declare that the above information is true and correct to the best of my knowledge. I will notify the treating practitioner if there are any changes to my medical history.
I understand the time set aside for my appointment is important, and I make a commitment to maintain these appointments once made. I understand that failure to provide the practice with at least 48 hours notice of appointment changes or cancellation will result in a broken appointment fee.
I understand that postponing my maintenance care visits may result in deterioration of my periodontal health.
I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents.
I understand that payment is due on the day of service. I also understand that I am responsible for payments if outstanding accounts are sent to a debt collection agency.
I understand that I am responsible for making claims to receive dental insurance rebates.

I UNDERSTAND AND AGREE THAT ALL INFORMATION AND MEDICAL CONDITIONS PROVIDED ARE CORRECT *

Signature *

Draw signature|Type signatureClear

Save and Complete Later