Medical History Form

Personal Details

Title

Full Name *

Preferred Name

Email *

Gender *

Date Of Birth

Mobile *

Phone(work)

Phone(home)

Home Address

Name of Person to contact in case of emergency

Are we able to contact this person with regard to your treatment?

Emergency Contact Number

Do you have a private Health Fund?

Which Fund?

Is another member of your family a patient at our office?

Name of Family Member

Occupation

Person responsible for fee's (if not self)

Details of Medical Practitioner

Name of Doctor

Phone

Medical Practice Name

Medical History

Are you being treated by a doctor at present? *

Details *

Do you normally require antibiotic cover before dental work? Recommended by your Dr or Rheumatologist *

Details *

Are you allergic to any medicines or drugs? *

Details *

Do you have any other known allergies? (Including latex) *

Details *

Do you smoke? *

Details *

Are you taking any tablets or medicines (prescribed or over-the-counter) at present? Please List *

Details *

Are you pregnant? Or breastfeeding? (if applicable) *

Details *

Have you had any abnormal reactions to local or general anaesthesia? *

Details *

How did you find us?

Name of Patient / Doctor who referred

Name of Person / Platform

DO YOU HAVE, OR HAVE YOU HAD, ANY OF THE FOLLOWING MEDICAL CONDITIONS?

Anaemia *

Radiation Therapy *

HIV/AIDS virus *

Blood disorder *

Sleep apnoea / snoring / sinus trouble *

Leukaemia *

Diabetes Type 1 *

Low blood pressure *

Epilepsy *

Stroke *

Nervous condition *

Heart complaint *

Transplanted organ or marrow *

Prosthetic implant e.g., Artificial hip *

Heart valve disorder *

Are you taking anticoagulant/ blood thinner medications (e.g. Warfarin, Aspirin)? *

Are you vaccinated against Covid 19? *

If ticked yes to any of the above - Please list any other medical condition/s:

High blood pressure *

Asthma *

Rheumatic fever *

Kidney disease *

Cardiac pacemaker *

Steroid therapy *

Diabetes Type 2 *

Stomach or digestive condition *

Lung disease *

Excessive bleeding *

Thyroid disease *

Osteoporosis *

Heart murmur *

Tuberculosis *

Hepatitis, A, B, C or other liver disease *

Are you taking bisphosphonates (e.g., Fosamax) for osteoporosis? *

Dental History

What service do you require? *

Do you experience sensitivity with hot/cold? *

Do you feel you grind your teeth? *

How long since your last dental appointment? *

Do you have sinus trouble? *

Does your jaw ever click or pop *

Cancellation Policy

Please confirm your appointment. We will contact you multiple times via sms, email and by phone prior to your appointment. You must reply to one of these contacts to confirm your attendance. It is as easy as replying yes to your reminder, alternatively you can call us.

We value your time and ask that you value the time we allocate to you. If you are unable to make your appointment, please let us know as soon as possible so we can give that time to another client.

A missed appointment is defined as an appointment you do not show up for or an appointment that is cancelled with less than 24 hours’ notice. We reserve the right to charge you for your appointment that you fail to attend or notify us of cancellation with less than 24 hours’ notice.

Cancellation Policy Agreement *

I have read the above cancellation policy and agree to the set terms.

Authorization *

I authorise for Brisbane Dental and Denture Clinic to take photographs of my jaws, teeth and surrounding structures, before, during and after treatment. I understand that they will be used for dental records, personalised treatment plans, educational purposes and for social media outlets such as, Instagram and Facebook.

Signature *

Clear Signature

Personal Details

Details of Medical Practitioner

Medical History

Dental History

Cancellation Policy

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Brisbane Dental & Denture

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(07) 3172 1312

Elizabeth St Shopping Centre

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