Your Medical and Dental History (Online Patient Form)

To make an appointment at d-spa please contact one of our three practice locations or fill out the form below. We look forward to your inquiry and will respond as soon as possible.

Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation. If you would like any further information about how we use and protect your personal information, please ask one of our staff for our “Personal Information, Privacy and your Dentist” document. Click here for our privacy policy.

We also offer our Medical and Dental History form as a downloadable PDF that you can fill out and bring with you to your appointment.

Click here to download our PDF form.

 

Confidential Member Information
Title:
Surname:* Given Name:*
Date of Birth:*
Address:* Suburb:*
Postcode:*
Ph (home):*
Occupation: Ph (work):
Mobile Number: E-mail:*
Emergency Contact:* Telephone:*
Private Health Insurance Fund: Medical Practitioner:
Who can we thank for referring you to our practice?:
Medical Form

Have you ever experienced?

Do you have any other serious illness?:
Do you consider yourself to be in a high risk HIV category?
Artificial joint replacement, heart valve or any prosthetic implants
Have you had any past problems with dental treatment?:
Are you currently taking any medication? (Natural or Recreational)
If Yes, please list:
Are you allergic to Penicillin?
Are you allergic to latex?
Are you allergic to any other drugs or medicine?
If Yes, please list:
Have you had Cortisone in the past 12 months?
Females - are you possibly pregnant or breast feeding?
Are you a smoker?
Average number smoked per day:
Preventive Consultation

To help formulate an individual preventive program, we need to ask a few questions about your dental history and oral hygiene routine.

When was your last dental examination?:
When were your last dental x-rays?:
Your last professional dental clean?:

To prevent dental decay and gum disease, we recommend scheduling a recall appointment with the hygienist every 3-6 months. Dental xrays are taken every 12-24 months in order to examine between the teeth and gums. This allows us to work with you to achieve optimum oral health.

Are you experiencing any dental pain or discomfort?
Sharp pain / constant dull ache / throbbing / intermitting pain / unprovoked pain?
Do you experience any pain when biting or chewing?
Are your teeth sensitive to hot / cold or sweet?
When did the pain sensitivity begin?:
Fresh Breath & Dry mouth
Do you have an unusual taste in your mouth during the day?
Are you a mouth breather or have dry mouth during the day?
Do you suffer from bad breath?
Has anyone ever mentioned you have bad breath?
Do you suffer from frequent sinus problems?
Gum Health
When you brush or floss do your gums bleed?
When you floss do your gums smell?
Do you find food gets caught between your teeth easily?
Has anyone ever told you that you grind your teeth at night?
Do you suffer from headaches, backaches or neck pain?
Have you ever had any serious problems associated with previous dental treatment?:

How can we make your dental appointment more comfortable?:
Oral Hygiene Routine
Do you use a manual or electric brush?
How often do you brush?:
What best describes your toothbrush bristles?
What type of toothpaste do you use?:
Do you floss? How often?:
Do you use a tongue cleaner?
What mouthwash do you use?:

Would you say the refined sugar in your diet is:
How often do you drink coffee / tea? With or without sugar?:
Have you noticed your teeth are not as white as they used to be?
What would you like to change about your smile?:
Privacy Consent

Our practice respects your right to privacy. We realise that it is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our practice and to whom this information might be disclosed.

The policy of our practice is to follow these procedures:

1. The information collected will be used for the purpose of providing treatment & information to you. Personal information such as your name, email/address and health insurance details will be used for the purpose of addressing accounts to you, as well as processing payments and writing to you about our services, current health updates and any issues affecting your treatment.

2. We may disclose your health information to other health care professionals, or require it from them if, in our judgement, that is necessary in the context of your treatment in that event, disclosure of your personal details will be minimized wherever possible.

3. We may also use parts of your health information for research purposes, in study groups or seminars as this may provide benefit to other patients. Should this happen, your personal identity will not be disclosed to do so.

4. Your medical history, treatment records, x-rays and any other material relevant to your treatment will be kept here. You may inspect or request copies of our records of your treatment at any time, or seek an explanation from the dentist. Statutory fees will apply in relation to the types of access you seek. If you request an explanation of our records or a written summary, our usual fees apply to these services.

5. If any of the information we have about you is inaccurate, you may ask us to alter our records accordingly.

You can otherwise rest assured that your health information will be treated with the utmost confidentiality. Disclosure will not be made to any person not involved in either your treatment or the administration of this practice, without your prior written consent. If you have any queries or concerns about our handling of your health information, please do not hesitate to raise these concerns with our practice.

How did you hear about us?
Referral Source:    
Keep Informed Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
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Consent for Services

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.

 

* Please let d-spa know 48hrs before the appointment time of any changes, otherwise a $60 late cancellation fee will apply.

 

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