Medical History Form (New Patient) | Adelaide Dental Solutions

Your Personal Details:

Gender:

MaleFemale

Title:

Date of Birth:

First Name:

Preferred Name:

Surname:

Postal Address:

Postcode:

Mobile:

Home:

Work:

Email:

Occupation:

Nationality:

Would you like to be added to our mailing list: YesNo

Name of Health Fund:

Your I.D. No.:

Best confirmation method for appointment (please check): SMSTelephoneEmail

Person to contact in case of emergency:

Relationship:

Phone Number:

Information about your Medical/Dental History:

When was your last dental treatment approximately?

Last Dental Cleaning?

Do you feel nervous about your dental treatment?

GP Name:

Phone No:

Are you currently undergoing any medical treatment or had any surgery within the last 12 months? YesNo

Are taking any medication, drugs or pills now? YesNo

If yes, name medication and dosage:

Are you taking any Biphosphonate Medications?

Do you have any allergies?

Please indicate below if you have had, or have at present any of the following:

Females:

Are you pregnant? YesNo

Breast Feeding? YesNo

We request and expect payment at the time treatment. For your convenience we accept cash, cheques, eftpos, all major credit cards. Also note that you are responsible for any costs incurred by our practice for recovery of outstanding payments. I understand that payment of the account is my responsibility, and that my Health Fund (if any) will not cover the full amount. I understand to pay any expenses incurred or to be incurred in the collection of any overdue portion of this account.

Patient / Guardian Signature (Print Name):

Date:

Dental Patient Satisfaction Survey