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Date [dateToday]Patient Signature:
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Consent For Services ExtremelyModeratelyI herby give consent for a dental examination and understand that the information I have provided is accurate and will be kept confidential for dental purpose only.

I understand that payment is required on the day of treatment.

I understand that a minimum of 24 hours' notice is required if I need to cancel my appointment and late cancellation fees may apply.SlightlyNoHow long since your last dental visit and why?Does dental treatment make you nervous?What is the main purpose for your visit?Gaps between teethProblems brushing/ flossingDiscoloured teethAbility to eatYour smileMissing teethPrevious dental treatmentSilver FillingsCrooked teethExisting crowns, bridges or denturesDiscoloured fillingsDo you / have you ever smoked?
If yes, how many per day?Do you snore or suffer from sleep apnoea?Are you being treated for any other condition not listed?Patient (Please provide name so that we can thank them)Other Medical Practitioner Walked Past Phone (W) :Phone (M) :[salutation]TitlePostal Address:TuberculosisEpilepsyPsychological DisordersRespiratory ProblemsDizzinessRheumatic FeverSinus ProblemsArthritisOsteoporosisPregnantBreast FeedingRadiation Therapy AsthmaCancer / TumoursClicking or pain in jaw jointsSensitivity/ Pain when eatingGrinding or clenching teethStaining of teethAre you taking or have taken Bisphosphonate (osteoporosis) drugs?Roughness of existing fillingsBleeding gumsBad tasteHead / Neck acheBad breath Food trapping between teethAre you concerned with?Dental information: Excessive BleedingParent/ Guardian Phone:Are you concerned about or experiencing any of the following dental problems?DiabetesSensitivity/ Pain to hot and coldInternet/ Website Yellow PagesDo you have any allergies to drugs, medications, latex or other? Describe the adverse reaction.Emergency Contact Phone:Occupation:Details only of the patient is under 18 years old.Last Name:NEW PATIENT
MEDICAL & DENTAL
HISTORY FORMD.O.BFirst Name:Parent/ Guardian Name:Where did you find out about us? Please tick:Live Locally Referral information:Email: Emergency Contact Name:Phone (H) :Are you currently taking any drugs, medications, inhalers or tablets? If yes, please list.Medical information continued:StrokeMedical information: Artificial JointsBlood DiseasesAnaemiaHeart MurmurHeart DiseaseGlaucomaFaintingHepatitis A, B, CHave you had any serious illness in the last 2 years? ExplainLiver DiseasePacemakerKidney DiseaseHIV / AIDSHigh Blood PressureHave you ever had any of the following? Please tick: