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mouthguard
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gap free checkup
Contact Us
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Medical History Form
Medical History Form
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Gender
*
MALE
FEMALE
N/A
Martial Status
Single
Married
Divorced
Legally Separated
Widowed
De facto
Address
*
Street Address
*
Suburb
*
State
*
Postal
*
Mobile Number
*
(000) 000-000
Email
*
Have you suffered recently from the following dental problems? Please tick the checkbox if YES.
Anaemia
Diabetes
Cancer
Excessive Bleeding
Blood Pressure
Arthritis
Radiation Theory
Blood Disease
Hepatitis A
Hepatitis B
Hepatitis C
Stroke
Osteoporosis
Pacemaker
Asthama
Thyroid Problems
Tuberculosis
Artificial Joints
Heart Disease/Murmur
Rheumatic Fever
Psychiatric care
Kidney Disease
Others
Doctor
Telephone Number
Have you had any other serious illness?
*
Yes
No
If yes, please explain:
Are you taking any medicines or tablets regularly (including any over the counter medicines, vitamin supplements, or herbal remedies)?
Yes
No
If yes, please list:
Do you snore?
Yes
No
Don't Know
If yes, have you had a sleep study or been diagnosed with sleep apnoea?
Yes
No
Do you suffer from any allergy?
*
Yes
No
If yes, please explain
Are you a smoker?
Yes
No
If yes, how many years have you been smoking?
Are you pregnant?
Yes
No
If yes, how many weeks?
Next of Kin (in case of emergency):
Telephone Number
Consent of Services: By ticking the text box below and submitting button, you are agree with the following:
This is to certify that I, the undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetic as indicated and I will assume responsibility for the fees associated with these procedures.
I shall pay any legal costs, including solicitor and own costs, tracing costs and any collection commission incurred by PRODENTAL CLINIC as a result of my failure to pay any amounts due to PRODENTAL CLINIC.
I have been advised that it is the policy of the PRODENTAL CLINIC to list any defaulting accounts with Equifax.
(if < 18 years of age) Parent/Guardian Details:
First and Last Name
Date
DD-MM-YYY
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Name
*
First
Last
Email
*
Phone Number
*
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