NEW PATIENT DENTAL HISTORY FORM
Please note that all information on this medical form will remain strictly confidential. Please
complete in CAPITAL LETTERS
Surname First Name
Date of Birth / / Occupation
Phone (H) Address:
Phone (W)
Mobile
Email address
Emergency Contact Do you have health
☐ YES ☐ NO
Name insurance
Insurance Name
Phone No
Insurance No
To complete if the patient is under 18 years old
Guardian Name & Phone No
Medicare Card No: Ref No
Are you eligible for any of the following scheme
☐ Child Dental Benefit Scheme MEDICARE
☐ DVA DVA Card No
☐ Government Voucher
Referral Information (MUST BE FILLED)
☐Internet/website ☐Yellow Pages ☐Shop A Docket ☐Flyers ☐Newspaper
☐Walked Past ☐Facebook ☐Freebies Centro ☐Billboard Sign ☐Google Search
☐Child Care Centre ☐ OZ Little Directory ☐Stall ☐Radio ☐TV Display/Cinema
☐Family/Friends: NAME PLZ_____________________________________________________ ☐Other_____________
MEDICAL HSITORY
Name of your GP GP Phone
Your doctor’s address
Current Medication Plz specify
Have you ever had any of the following? Please tick those that apply:
☐Anemia ☐Fainting ☐Pacemaker
☐Artificial Joints ☐Glaucoma ☐Radiation Therapy
☐Asthma ☐Heart Disease ☐Respiratory Problems
☐Blood Disease ☐Heart Murmur ☐Rheumatic Fever
☐Cancer ☐Hepatitis A, B, C ☐Sinus Problems
☐Dizziness ☐High Blood Pressure ☐Stroke
☐Epilepsy ☐Kidney Disease ☐Tuberculosis
☐Excessive Bleeding ☐Liver Disease ☐Bleeding Problems
☐Diabetes ☐HIV/AIDS ☐Psychological Disorders
Are you pregnant? ☐Allergy If Yes Please Specify:________________________________________
If yes, how many months?
DENTAL HISTORY
Are you concerned about or experiencing any of the following dental problems? (Please tick as many as it applies)
☐Sensitivity to hot or cold ☐Food Trapping between your teeth ☐Clicking/pain in jaw joints
☐Staining of your teeth ☐Discolored filling ☐Roughness of existing filling
☐Bleeding Gums ☐Bad Breath ☐Sensitivity when eating
☐Head/Neck Ache ☐ Grinding or cleaning of your teeth
Are you concerned with: (Please tick as many as it applies)
☐Existing Crown, bridges or dentures ☐Gaps between your teeth
☐Missing teeth ☐ Your Smile ☐Discoloration of your teeth
☐Crooked tooth ☐ Silver Filling ☐Previous Dental treatment
☐Tooth clean techniques (e.g. brushing/flossing) ☐Ability to eat
What was the main purpose of your visit today?
How long since your last dental visit?
__________________________________________________________________________________
Does dental treatment make you nervous?
☐ No ☐ Slightly ☐ Moderately ☐ Extremely
CONSENT FOR SERVICES
I, the undersigned, consent to the performing of dental and oral surgery procedures agree to be necessary or
advisable, including the use of local anesthetics as indicated and I will assume responsibility for the fees
associated with those procedures
I understand that the practice requires as minimum 24 hours’ notice if I need to cancel my schedule appointment
and that a cancellation fee of $75.00 could be incurred if I fail to do so
I hereby consent to the use of any study models, x-rays, computer images and photographs at various dental
seminars, lectures and publication that the dentist may author.
I am aware that payment is required on the day of treatment.
Patient’s (or parent) Signature:_________________________________ Date of Signature:_________________________
Parent Name if Patient is Minor:________________________________________________________________________
