Personal Information
Title:
Surname:*
First Name:*
Preferred Name:
Date of Birth:*
Address:*
Suburb / Town:*
Postcode:*
Home Phone:
Mobile Phone:*
Work Phone:
Your Email:*
Occupation:*
Employer:
Next of Kin
Name:
Relationship:
Phone:
Medical Information
Medicare Number:*
Position on Card:*
Expiry Date:*
Private Health Fund (if any):*
Private Health Fund Number:
Private Health Fund Position on Card:
Do you have extras cover?:*Yes No
Dept. Veteran Affairs (DVA):Yes No
DVA Card No:
DVA Expiry Date:
Dental History
How long since your last dental examination?—Please choose an option— 0 - 6 months 1 year 2 years 3 years Longer
Please outline any dental concerns you have:
Are you interested in teeth whitening?Yes No
Do you snore or experience restless sleep?*Yes No
Do you experience jaw pain or discomfort?*Yes No
Current Smoker?*Yes No
If yes, how many per day?
Previous Smoker?*Yes No
How long since you have quit?
Are you of Indigenous, Torres Strait Islander or South Sea Islander heritage?*Yes No
Reminders
SMS Mobile Home Phone Work Phone Email
Medical History
Who is your General Practitioner?
Phone:
Have you had, or are you suffering from any of these conditions? Please indicate Yes or No for each.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Any other conditions:
Are you currently pregnant?*Yes No
Have you had surgery in the past 6 months?*Yes No
If you have had surgery in the last 6 months, list the procedure(s) below:
Please list any medications you are taking, including medication name and strength, dose taken - quantity and when taken, duration of use and purpose.This includes prescribed and over the counter medication that you are taking, including non-oral (Eg; Eye Drops, Inhalers, injections, COVID-19 vaccination etc)
Please list any allergies to drugs, foods or materials, including name, nature of reaction and when reaction occurred:
Consent for Services
Ticking the following box certifies that I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.Yes
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