Gender: —Please choose an option—MALEFEMALE
Title: —Please choose an option—MrMrsMissMsDrProf
Date of Birth:
Whom may we thank for referring you to us?
Please tell us why you’ve been referred to us?
In the event of an emergency please contact:
How would you like us to confirm your future appointments?
Please circle yes/no to which of the following you may have had in the past or have at present.
Heart Condition (surgery/disease/attack)Heart Murmur or Rheumatic FeverHigh Blood PressureArthritis/RheumatismArtificial JointsFainting or Dizzy spellsEpilepsy or Seizures
Chemotherapy or Radiation treatmentCancer/ TumoursCorticosteroid therapyHIV/AIDSThyroid problemsNervous/ AnxietyHepatitis A B C D ENeurological Disorders
Stomach ulcersDiabetesSinus troublesAsthma or HayfeverKidney or liver troublesAnaemia or other blood disordersAllergies to anaesthetics/penicillin/medications/latex
Do you have any ALLERGIES? NOYES
If yes, please list
Do you have or have you had previously any disease, condition or problems not listed? NOYES
Your medical doctor’s name:
Medical doctor’s number:
Are you taking any medications, drugs or pills? NOYES
If yes, which ones?
Are you taking or have you previously taken any bisphosphonate medications (e.g. Fosamax, Zometa, Didronel, Relast, Boniva, Atelvia, Aclasta, Actonel, Aredia, Binosto, Skelid)? NOYES
Have you been admitted to hospital before? NOYES
If yes, for what?
Do you smoke? NOYES
If Yes, how much? Number of times a day: For how many years:
Do you drink alcohol? NOYES
If Yes, how much per week?
Are you pregnant? NOYES
How many months:
Person responsible for paying the account (if not yourself)?
Do you have private dental health cover? NOYES
If so which company?
I understand that the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider, who may release such information to you. I will notify the dentist of any changes in my health or medication.
I give permission the dentist and their staff to take photographs, X-rays, models and other diagnostic aids deemed appropriate to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
In connection with dental services, I agree and consent to allow the photographs and videos taken before, during and after completion of my dental treatments to be used for dental records, research, education, public relations, patient counseling or other purposes. I further agree and consent that the photographs relating to my dental care may be published and republished either separately or in connection with each other in dental photo albums, professional journals or dental books
I agree to the terms and conditions listed above