New Patient | ITeeth

Medical History Questionnaire

It is important for your dentist to have your medical history and understand your health needs before any examination or treatment is carried out. Medical information will be kept strictly confidential and in accordance with the Privacy Act 1988.

Your Personal Details

Title

Date of Birth

First Name

Surname

Home Address

Address

Suburb

State

Postcode

Postal Address

Address

Suburb

State

Post Code

Home Phone

Mobile

Work Phone/Mobile

Email Address

Health Fund

Membership No.

Patient ID

Medicare No.

Pensioner or Health Care Card No.

Patiend ID

Expiry

Veterans' Affair Card No

Details of Contact in Case of Emergency

Emergency Contact

Relationship to Patient

Telephone

Medical Questionnaire - Private and Confidential

Please answer these questions to the best of your ability or discuss them with your dentist, information about your medical history is for your dentists use only and will help your dentist delivery optimal care to you

If Yes, Details

Please indicate if you have EVER had any of the following?

Current Medications (prescription, over the counter or herbal)

Allergies (medicines i.e. penicillin, substances or materials (latex/rubber))?

Nik Known

Yes

Have you ever had any adverse reactions from prescribed medication?

Have you ever had any adverse reactions following dental treatment?

Have you ever had any adverse reactions from local anaesthetic?

General Practitioner/Practice

Phone Number

Have you seen your GP during the past year?

Dental History

Are you interested in any of the below treatment options?

Responsible Party for Payment

Name/Business/Institution of Responsible Party

Contact Number

I agree that the above is a true and accurate record. Payment on the day is required. Any expenses, costs or disbursements incurred by Encounter Bay Dental & Implants in recovering any outstanding monies including debt collection fees and solicitor costs shall be paid by the responsible party above. I further acknowledge that failure to attend any appointment without notice may result in a failure to attend fee.
PLEASE NOTE: This medical history questionnaire and ensuing clinical records will be electronically copied to your clinical record file and the original will be subsequently destroyed. By signing this document, you agree to this process. this form is a guide only and you should discuss any relevant matters with your dentist prior to the commencement of any dental treatment. Orthopantomogram (OPG) and Cone Beam CT (CBCT) if needed will be taken at your initial visit. These films are not reported on by a radiologist, we predominantly will be focusing on dental pathology.

Date:

Signature

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