Number:Please take your time to answer these questions.This will asssit us greatly in our effort to provide the best dental treatment for you. This is, of course, confidential. Preferred Name:Mobile:Excessive Bruising, Please specify: Title:Previous dental X-Rays were taken?Is Another Family Member a Patient at our Practice?Are you taking any blood thinning medications (eg. Warfarin, Marevan, Aspirin, Coumadin, Areda, Zometa)?Work Number:Next of Kin Name:Preferred Contact Method for Appointment?Last Name:Are you currently taking any medications? If yes, please listHave you ever considered or had Cosmetic Injections / Dermal Fillers? Yes / No
If yes, please specifyHow long since your last dental visit?Number:Name and Location of previous dentist:How did you find out about us?Suburb:Post Code:Email:Date of Birth:Doctors Name:Purpose of todays visit?Are you comfortable during your visits to the dentist?Are you currently taking osteporisits medication (eg. Actonel, Fosamax, Aredia, Zometa)? If yes, please listName:Address:Are you pregnant? First Name:Please answer the following:Does floss ever tear between your teeth?

Does food ever get jammed between your teeth?Y

Y

Does your jaw click or Hurt?Do you experience sensitivity with Hot/ Cold?Consent for Treatment:Have you ever had Gum disease?Have you had orthodontic treament?

Do you gums ever bleed when brushing?
Do you bite your lip or cheek often?

Have you ever had your bite adjusted?Do you grind your teeth?

Do/ Did you smoke?

Signature will be recorded later

Do you wear a mouthguard?

Do you think you have occasional bad breath?

Do you snore/ stop breathing during sleep?

Patient / Guardian Signature:I hereby authorise the dentist or designated team to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. 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 I can ask for a complete recital of any possible complications. I agree to be responsible for payments of all services unless other arrangements have been made. I authorise that this data may be reviewed by team members of this dental practice.