MEDICAL AND DENTAL 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.



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Have you had any of the following ? ( Please tick appropriate box ( es ) )

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Weeks

    
                                          

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.

Click This Area!  Your signature will go here!
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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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