New Patient

Medical History Questionnaire

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

Details of Contact in Case of Emergency

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

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

Dental History

Are you interested in any of the below treatment options?

Responsible Party for Payment

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.

Sign Here