Title Title Mr Mrs Miss Ms Master Dr Other

First Name *

Last Name *

Date of Birth (DD/MM/YYYY) *

Occupation

Home Address *

Phone *

Preferred Method of Reminders * Preferred Method of Reminders * SMS Email

Email Address *

Emergency Contact Name *

Phone Number *

Health Insurance

Policy Number

Reference Number

How did you find us? How did you find us? Google Social Media Health Fund Health Engine Friend/Family (Name)

Name of Friend or Family

Do you smoke? * Do you smoke? * Yes No

Are you pregnant? * Are you pregnant? * Yes No

Allergies (Latex/Medication/Etc)

Anaemia/Blood Disorder * Anaemia/Blood Disorder * Yes No

Epilepsy or Seizures * Epilepsy or Seizures * Yes No

Asthma * Asthma * Yes No

Heart Attack/Murmur * Heart Attack/Murmur * Yes No

Artificial Joints * Artificial Joints * Yes No

Hepatitis A/B/C * Hepatitis A/B/C * Yes No

Arthritis * Arthritis * Yes No

HIV * HIV * Yes No

Blood Pressure (High/Low) * Blood Pressure (High/Low) * Yes No

Mental Health Condition * Mental Health Condition * Yes No

Blood Thinners * Blood Thinners * Yes No

Osteoporosis * Osteoporosis * Yes No

Cancer (Past/Present) * Cancer (Past/Present) * Yes No

Pacemaker/Cardiac Surgery * Pacemaker/Cardiac Surgery * Yes No

Cholesterol (High/Low) * Cholesterol (High/Low) * Yes No

Reflux * Reflux * Yes No

Diabetes (Type 1/Type 2) * Diabetes (Type 1/Type 2) * Yes No

Rheumatic Fever * Rheumatic Fever * Yes No

Additional Medical History not listed

Current Medications (include natural medications)

Ticking This Is The Same As A Signature: * Ticking This Is The Same As A Signature: * I accept the ultimate responsibility for payment of all dental treatment carried out on myself, and may include any fees generated from missed appointments or appointments cancelled with less than 24 hours notice, and agree to pay all fees at the time of the appointment unless prior arrangements have been made. In default, I agree to pay all account handling fees and collection charges for overdue accounts.

Todays Date For Signature *