Medical History Questionnaire

Are you filling in this form*

for yourself
on behalf of someone else

Your Title

Your Name*

First Last

Your Email*

Patient's Title

Patient's Name

First Last

Date of Birth

DD

MM

YYYY

Address

Street Address City ZIP / Postal Code

Home Phone

Work Phone

Mobile

Fax

Patient's Email

Occupation

Emergency Contact

Name

Number

Relationship

Person responsible for payment

First Last

Phone Number

Relationship to patient

To which Health Fund do you belong?

Is another member of your family a patient of the practice

Yes

Name(s)

Name of parent/guardian

Whom may we thank for your referral?

To ensure our treatment is compatible with your present state of health, please answer the following:

I have confidential medical information I do not wish to write down. I would prefer to speak to the dentist about this.

Yes

Are you, at present, receiving medical treatment?

Yes

Details

Name of your doctor

Phone

Please list any medication or tablets you are taking:

Please tick if you have had or been treatment for any of the following:

Diabetes Type

Hepatitis Type

Allergies to medications

Yes

Details of Allergies to medications

Allergies to latex
Bone disorders or diseases

Details

Are you pregnant?

yes

Due date?

Have you had surgery for the following:

Artificial hip
Knee reconstruction
Artificial heart valve
Prosthetic implant

Date of Artificial hip Surgery

Date of Knee reconstruction surgery?

Date of Artificial heart valve surgery

Date of Prosthetic implant

Any other relevant medical information – state below

How often do you have dental examinations?

How long since your last dental visit

Previous dental x-rays were taken?

Less than 1 year ago
More than 1 year ago

What is the main reason for the visit today?

Please tick if you have had any of the following:

Have you been diagnosed with Obstructive Sleep Apnoea?

yes
no

Do you smoke?

yes

How many per day

Is there anything else you would like us to know?

How did you hear about us?

Who referred you?

Please select method of communication?

SMS
Telephone
Email
Letter
None

CONSENT FOR TREATMENT

1. I hereby authorise a dentist or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by a dentist to make a thorough diagnosis of dental needs.

2. Upon such diagnosis, I authorise a dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. I agree to the use of anaesthetics, sedatives and other medication as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

4. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. I also understand that for any reason recovery of funds is required; any costs involved will be at my expense.

Signed

Parent/Responsible Party Signature

Relationship

Today's Date*

I would like to opt in to receive a newsletter and be among the first to receive special offers from my dental practice.

yes

Captcha

Greenwood Dental Medical Form

Emergency Contact

CONSENT FOR TREATMENT

Medical History Questionnaire

Greenwood Dental Medical Form

Emergency Contact

CONSENT FOR TREATMENT