Welcome to Beachside Complete Dental Care and Dental Implant Centre, so that we may provide you with the best possible care please complete all sides of this medical history form. All information is completely confidential.
Preferred title MrMasterMrsMissMsDr
Date of Birth
Surname*
First name*
Preferred name
Address*
Suburb*
Postcode*
Mobile number*
Home number
Work number
Email*
Parent/Guardian/Carer name (if applicable)*
Do you have any special cultural or spiritual needs?NoYes
On a scale of 1-10, how would you describe your level of anxiety about your visit today?
Least 12345678910 Most
GP Clinic/GP name
Medical Emergency contact*
Phone number*
PLEASE NOTE THAT OUR POLICY IS TO RECEIVE PAYMENT ON THE DAY OF YOUR TREATMENT WE ACCEPT CASH, EFTPOS, VISA, MASTERCARD AND AMERICAN EXPRESS In the event payment is not received in full, the person responsible for fees is responsible for recovery service fees.
Are you aware that full payment on the day is required?YesNo
Person responsible for fees SelfOther
Name
Phone number
Address
Cancellations: 48hrs notice of any cancellation is kindly required or a cancellation fee may be charged.
Patients who have dental insurance: Item numbers are used as accurately as possible to describe the treatment received but cannot be claimed for anyone other than the person who received the treatment. The rebate is determined by your individual health insurance policy. Our surgery is not responsible for any concerns you may have regarding your health fund.
Do you have private health insurance?YesNo
Please selectHospitalDental
Health fund name
Member number
Serial number
Are you eligible for the Child Dental Benefits Schedule (CDBS)? YesNo
Medicare card number
Ref. #
Is this consultation related to a Workcover or a work-related injury or transport accident?YesNo
Who recommended our practice to you?
Existing patient
Patient Name
Beachside Dental WebsiteStaff MemberGoogle searchDentistPassing byDoctor
To the best of your knowledge do you or have you suffered from the following? If possible, please provide approximate date of diagnosis.
Please Tick
Questions
DETAILS
NoYes
High Blood Pressure
Low Blood Pressure
Osteoporosis medication or injections
Heart Ailment or Heart Murmur
Congenital heart Problem
Heart Valve/Pin/Stent
Pacemaker
Rheumatic Fever
Bleeding Disorder
Diabetes
Liver or Kidney Disease
Hepatitis A / B / C / D / E
HIV / AIDS
Asthma
Cancer
Chemotherapy/Radiation Therapy
Physical, sensory, or learning disabilities
Stroke
Arthritis
Mental health issues
Respiratory
Back or neck problems
Neurological (nerve problems)
Digestive problems
Lung disease
Infection diseases
Epilepsy
Bone Disease / Disorder
Tuberculosis
Hormone Supplements
Hearing impairment/difficulties
Knee / Hip / Joint Replacement
Intellectual difficulties
Ladies, are you pregnant? If so, how many weeks?
Due date:
Please state any major surgery you have had in the last five years:
Do you/have you received any treatment for jaw related problems?
Do you smoke?
If yes, how many per day?
Do you drink alcohol regularly?
Any other relevant medical history?
Do you have any allergies?
NoYesMaybe
Do you have any adverse reactions to drugs?
Are you allergic to Penicillin?
Are you allergic to latex?
Please state any allergy/reaction
Emergency plan
There are many medications that may impact upon your oral health or the treatment we plan for you. Please indicate any medications that you are currently taking or have taken recently (including natural therapies). Alternatively, a list from you GP can be attached.
Does your jaw click or hurt?
Have your teeth chipped or worn down?
Do you grind your teeth?
Does food get stuck between your teeth?
Do your gums bleed when you clean your teeth?
Do you suffer from bad breath?
Are you interested in teeth whitening?
Have you had previous gum problems?
When was your last Dental Examination?
When were your last dental x-rays?
The purpose of my visit today is
Do you consent to receiving a Dental Examination and Treatment?YesNo
DATE
Parent/Guardian/Carer name*
Please tick this box to confirm that you have read and understood our Privacy Policy, and consent to use of your health information in this way Yes, I've read the Privacy Policy*.
We are open 6 days a week.
Monday to Friday 8am - 6pm and Saturday 9am - 1pm
Call us:(03) 9781 3633
Name*
Phone
Preferred Date
Comments*
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