Dental Treatment Appointments | All Smiles Dentistry

Title*

Given Names*

Contact Number*

Date Of Birth*

Email ID*

Occupation*

Home Address*

Emergency Contact Name*

Emergency Contact Number*

Private Health Fund*

If under 16 Guardian/Career Name*

How did you find us? (Google, website, Yellow pages, Referral, Walk in)*

Do we see any other members of your family & what is / are names/ (Where appropriate we can put you on a family account)*
YesNo

Dental History

When was your last dental visit*

Have you had x-rays of your teath in the last 2years*
YesNo

What is the main purpose of your teeth in the last 2years*

Do you grind or clench your teeth*
YesNo

Do you wear a mouthguard occlusal, splint, snoring device or denture*
YesNo

Do you wear a mouthguard, occlusal splint, snoring device or denture? Do you have any other dental professionals providing you care (i.e. GP, Orthodontist, Periodontist, Endodontist)? If yes please provide their details:*
YesNo

Medical List

Medical History Do you have any allergies e.g. Penicillin? Please List:

Do you have a regular GP or Medical Centre that you visit?*YesNo
( If yes please provide the following details: )
Name:

Phone Number

Do you have, or have you had, any of the following? Please tick all that apply:
Excessive BleedingAlzheimer's DiseaseGlaucomaHeart AttackCongestive Heart FailureAngina PectorisHeart MurmurArthritisHepatitis A,B,CArtificial Heart ValveHigh Blood PressureArtificial JointKidney DiseaseAsthmaOrgan TransplantAutismOsteoporosisCancerPace MakerChemical Dependency AlcoholPregnancy (How many Drugs months?)Congenital Heart Defect / DisorderRadiation / ChemotherapyChron's DiseaseRheumatic FeverDepression / Nervous DisordersStrokeDiabetesThyroid problemsEpilepsy or SeizuresTrigeminal Neuralgia

Have you ever had or are you suffering from any medical conditions not mentioned in the table above? Please give details:*

Are you currently taking any bisphosphanates such as Fosamax, Actonel etc? Are you taking any strong anticoagulants or antithrombotics such as Plavix or Warfarin?* YesNo
If yes then state the Medicine:

Have you been advised by your Doctor to take pre-medication before dental treatment?*
YesNo

Do you smoke?*
YesNo

Are you taking any medications? Please List:

CONSENT FOR SERVICES

- I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetic and other medication as indicated and I will assume responsibility for the fees associated with those procedures.

-I understand that the practice requires at least 24 hours notice if I need to cancel my scheduled appointment and that a cancellation fee may be incurred if I fail to do so.

- I hereby authorize the dentist or the designated team to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.

- I am aware that payment is required on the day of treatment.

- We provide a courtesy to our patients a preventative recall program that offers a call service if you have not been to the practice in 6 months.

New Patient Medical History Form

New Patient Medical History Form

Patient Details

Dental History

Medical List

CONSENT FOR SERVICES

24 Hour Emergency Contact

(02) 9477 1191