Title Surname This field is required. Given Name This field is required. Date of birth This field is required. Occupation Address This field is required. Suburb This field is required. Postcode This field is required. Phone Home Mobile This field is required. Email This field is required. Person responsible for account (if other than above) Health Insurance Fund Name Member Number Member prefix number on card DVA Gold card number Medicare No Name of person to contact in case of an emergency Relationship to patient Phone number GP's Name Phone number Whom may we thank of referring you to us? Please circle the correct answers to all questions below: Do you have, or have you ever had, any of the following conditions? Y/ N High blood pressure This field is required. Please circle. Please specify. Y/ N Rheumatic fever This field is required. Please circle. Please specify. Y/ N HepatitisA/B/C This field is required. Please circle. Please specify. Y/ N Bleeding or blood disorders This field is required. Please circle. Please specify. Y/ N Asthma This field is required. Please circle. Please specify. Y/ N Diabetes Type1or2 This field is required. Please circle. Please specify. Y/ N Epilepsy This field is required. Please circle. Please specify. Y/ N HIV / AIDSHIV/AIDS This field is required. Please circle. Please specify. Y/ N Women: are you pregnant? This field is required. Please circle. Please specify. Y/ N Are you allergic to Penicillin? This field is required. Please circle. Please specify. Y/ N Are you a smoker? This field is required. Please circle. Please specify. Y/ N Are you currently taking any medicine or tablets ? If yes, please specify: This field is required. Please circle. Please specify. Y/ N Do you suffer from any other illness, disabilities or medical condition? If yes, please specify: This field is required. Please circle. Please specify. Y/ N Are you or have you ever taken bisphosphonates, bone density medication? If yes, please specify: This field is required. Please circle. Please specify. Y/ N Heart trouble of any kind? If yes, please specify: This field is required. Please circle. Please specify. Y/ N Have you been to hospital or had any medical treatment in the past 12 months? If yes, please specify: This field is required. Please circle. Please specify. Y/ N Do you have any other allergies? If yes, please specify: This field is required. Please circle. Please specify. Y/ N Have you ever had any adverse reaction to previous dental treatment? If yes, please specify: This field is required. Please circle. Please specify. Please note that the dentist and staff have an ethical obligation to keep this information secret and guarantee confidentiality. By ticking this box I agree to pay all costs related to recovery of overdue accounts, including debt collection, solicitor and legal fees. We may charge a cancellation fee if appointments are broken without 24 hours notice. This field is required. Please fill in the required field. Your form has been submitted.
