PATIENT DETAILS

Title *

First Name *

Family Name *

Preferred Name

Date of Birth *

Gender *

Address *

Postcode *

Mobile Phone *

Home Phone

Work Phone

Email *

Occupation *

Emergency contact

Name *

Relationship *

Phone *

Person responsible for payment of accounts

Health fund

Which Health Fund do you belong to? *

Member Number *

Ref *

Is there another family member who visits our practice? *

How did you find us or who may we thank for recommending you to our practice? *

MEDICAL HISTORY

Do you have or have you ever had any of the following:

Heart problems *

YesNo

Congenital heart disease *

YesNo

Previous Infective Endocarditis *

YesNo

Heart attack *

YesNo

Mitral valve prolapse *

YesNo

Cardiac Pacemaker *

YesNo

Artificial heart valve *

YesNo

High blood pressure *

YesNo

Blood disorders *

YesNo

Excessive bruising or bleeding *

YesNo

Osteoporosis (low bone density) *

YesNo

Diabetes *

YesNo

Type 1Type 2

HIV or AIDS *

YesNo

Hepatitis A B C, other liver disease *

YesNo

Urinary tract or kidney disease *

YesNo

Artificial joint *

YesNo

Epilepsy (fits) *

YesNo

Stroke *

YesNo

Thyroid disease (including goitre) *

YesNo

Tuberculosis (TB) *

YesNo

Asthma or Breathing Problems *

YesNo

Neurological disorders *

YesNo

Anxiety or depression *

YesNo

Gastroesophageal reflux disease (GORD) *

YesNo

Inflammatory bowel disease *

YesNo

Chemotherapy / Radiotherapy *

YesNo

Treatment for cancer *

YesNo

Allergies *

YesNo

Organ, stem cell or bone marrow transplant *

YesNo

Arthritis *

YesNo

Sinus trouble *

YesNo

Snoring or sleep apnoea *

YesNo

Please provide details of any medical condition not listed or details of any condition you ticked “yes” to

Name of Medical Doctor

Practice

Phone

Please list any medications, pills, supplements or over the counter medications that you may be taking

Please specify

Any other medications you are unable to take?

Do you smoke? *

NoNo, I quitYes

When?

For how long?

How many?

Have you ever had Botox or Fillers? *

YesNo

Was this within the past two weeks? *

YesNo

FEMALES

Are you pregnant? *

YesNo

When are you due?

Are you breastfeeding *

YesNo

DENTAL HISTORY

When did you last visit the dentist? *

Have you or are you whitening your teeth? *

YesNo

What do you currently do to look after your teeth at home? *

Previous dental x-rays taken how long ago? *

DECLARATION

In signing this form I acknowledge that this represents an accurate medical history and I will advise of any changes to my medical history in the future. I understand all medical details will be treated with complete professional confidentiality. I have read the privacy document provided by this practice.

Payment is required on the day of treatment. In the event of an account being in default the customer shall be liable for all resulting costs arising from the recovery, which includes the account in full and legal costs including demand costs. Full trading terms and privacy statement are available on our website, or a copy may be provided by reception upon request.

Signed *

Draw signature|Type signatureClear

(parent or guardian if under 18 years of age)

Date *