Medical history form

When starting a new treatment plan, we'll need a medical history for the patient.

If you've been directed here by our staff, or would just like to get started, please fill in the form below. This will be uploaded to our system ready for your first appointment.

Patient details

Title

Surname

First name

Preferred name

Address

Postcode

Home phone

Work phone

Postal address (if different to above)

Mobile 1

Name

Mobile 2

Name

Which mobile number would you like to receive SMS courtesy messages to?

Email address

Date of birth

Have we treated any other family members? Yes No

If yes what are their names

How did you find out about our practice?

Financial information

Do you belong to a health fund? Yes No

If yes, which fund?

Please complete the details of the person responsible for the account

Self/Parent/Guardian Name

Address

Postcode

Mobile

Work phone

Home phone

Emergency contact

Name

Phone

Relationship to you

Medical history

General dentist

Address

Postcode

When did you last visit your general dentist?

What is the purpose of your next visit?

Have you had any serious health problems during the year? Yes No

If yes, please specify

Do you take any prescribed medication? (eg tablets, medicines or creams) Yes No

If yes, please specify

Do you have any allergies? (eg penicillin, codeine, nickel, latex, milk and milk products) Yes No

Have you ever had any bad reaction to any medical/dental treatment? Yes No

If you have answered yes to any of the above questions, please give details

Do you smoke? Yes No

If yes, how many per day?

Are you or could you be pregnant? Yes No

If you have ticked any of the above health conditions please give details below along with a current treatment

Have you been advised to take antibiotic cover for invasive dental procedures? Yes No

Name and address of General Practitioner

Name of person completing Medical History

Submit

We follow strict infection control protocols to prevent cross contamination and all instruments are put through a sterilization process before every procedure.

The information collected by our practice will be used for the purpose of providing treatment to you. Personal information will be used to address accounts to you, process payments and write to you about our services and any issues affecting your treatment.

Start your journey to beautiful teeth and
better alignment today.

(You don't need a referral)

Start today

Medical history form

When starting a new treatment plan, we'll need a medical history for the patient.

Patient details

Financial information

Please complete the details of the person responsible for the account

Emergency contact

Medical history

We follow strict infection control protocols to prevent cross contamination and all instruments are put through a sterilization process before every procedure.

Start your journey to beautiful teeth and better alignment today.

(You don't need a referral)

Start your journey to beautiful teeth and
better alignment today.