MEDICAL HISTORY FORM
It is important to know details about your medical history as this could affect your oral health care.
Please know that your confidentiality is our highest priority and this information will be handled in accordance with our privacy policy. Please ensure both pages of this form are completed.
Title
Mr.
Mrs.
Ms
Miss
Master
Dr
Gender
Male /
Female
Date Of Birth
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Year
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2023
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2015
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2013
2012
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Surname
First Name (s)
Preferred Name
Home Address
Suburb
Post Code
Home Phone
Mobile Phone
Work Phone
Occupation
Contact in case of emergency (Name)
(TEL)
Email Address
I do not wish to receive email newsletters
Your Dental Health Fund
BUPA
DVA
Medibank
HCF
CBHS
Other
Person responsible for fees (if not self)
Your Current General Practitioner and Suburb
I have confidential medical information that I do not wish to write down.
I would prefer to speak to a dentist about this. ( Please tick this box )
Have you had any of the following ? ( Please tick appropriate box ( es ) )
Heart valve disorder
YES
NO
Steroid Therapy
YES
NO
Cardiac pacemaker
YES
NO
Radiation Therapy / Chemotherapy
YES
NO
Heart murmur
YES
NO
Thyroid Disease
YES
NO
Any other heart problems
YES
NO
Bronchitis, emphysema
YES
NO
High or low blood pressure
YES
NO
Other lung disease
YES
NO
Artificial Joints/ prosthetic implant
YES
NO
Tuberculosis
YES
NO
Transplanted organ or marrow
YES
NO
Kidney Disease
YES
NO
Arthritis
YES
NO
Bleeding Disorder
YES
NO
Rheumatic Fever
YES
NO
Contact with HIV / AIDS virus
YES
NO
Hepatitis
YES
NO
A
B
C
D
E
Blood Disorder
YES
NO
Epilepsy
YES
NO
Breathing Difficulties / Asthma
YES
NO
Diabetes:
YES
NO
Type I
Type II
Growth Problem
YES
NO
Stroke
YES
NO
Do you Smoke
YES
NO
Have you ever been involved in Drug Use
YES
NO
Do you regularly drink Alcohol
YES
NO
Have you been involved in Blood Transfusions
YES
NO
Are you pregnant
NA
Yes
No
not sure
If so, how many weeks:
Weeks
How long since you’ve consulted a dentist
Have you ever had any difficulty with Tooth Extractions
Have you had any Serious Illnesses or Operations
Are you currently taking Medications ( please list )
Are you Allergic to any Medications ( include Latex )
Are you allergic to any anesthetics ( Local or General )
Would you like a Reminder for your appointment s
YES
NO
Preferred method of contact
Call
Fax
Email
Text Message ( SMS )
Is another member of your family a patient at our office
How did you hear about Us (please circle) Family & Friends (name)
Local Newspaper
Yellow Pages online
Yellow Pages book
mailbox delivery
Health Fund
Our Website
Roadside Banner
Google Search
Social Media
Other (please list)
Is there anything else you would like us to know
I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, that may be associated with general preventive and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit. I acknowledge that the nature and purpose of the forgoing procedures will been explained to me and if necessary and that I will been given the opportunity to ask questions before treatment commencement.
Patient’s Signature
Signature:
(please click the box below to sign your signature)
Start / Clear
Clear
Submit Signature
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Year
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Parent / Responsible Party’s signature
Relationship to Patient
I agree to settle my account in full today. TC dental is not responsible for the rebate negotiations between you and your healthfund. Regardless of the healthfund rebate TC Dental expects and appreciates all patients to settle their account in full at the completion of each appointment.
We accept all major credit cards (excluding Diners Club), Personal Cheque, Eftpos and Cash.
We also provide service for direct private health fund claims .
Please know our surgery sincerely values you, your family and your time. Although we do make every effort to keep our schedule, as a medical faculty, emergencies can arise.
Please ask our receptionist if she can be of assistance in any way, or if you have any queries regarding our privacy policy.
We always welcome your referrals!
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Year
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2024
Submit