Do you have, or have you ever had any of the following?
AsthmaRheumatic FeverHeart AilmentThyroid DisorderEpilepsyArthritisDiabetesBleeding DisorderHepatitisBlood Thinning MedicationLiver/Kidney/DiseaseProsthetic Heart ValveHigh/Low Blood PressureTumour/CancerAnaemiaNerve/Neural ProblemHIV/AIDS PositiveTuberculosisOsteoporosis Medication (Fosamax)





Are you allergic to any of the following?
LatexPenicillinAspirinCodeine Sulphadrugs







Do you wish to receive information from the dentist regarding the following?
Teeth whiteningCrowns/VeneersTooth GrindingOrthodontics
How do you hear about our surgery?



I agree the following policy.
I have completed this form to the best of my knowledge and understand that failure to make a full disclosure may place ME under medical risk. I understand the personal and health information collected will be kept by the practice with strict confidence, unless required to be sent to other dental practitioners to aid in my treatment and I consent to this. I also give permission to the practice to use the above contact details to send me appointment cards and reminders of any sort.

PLEASE NOTE WE REQUIRE FULL PAYMENT ON THE DAY OF TREATMENT. WE ACCEPT CASH, EFTPOS, VISA AND MASTERCARDS.
A $50 FEE MAY APPLY IF YOU FAIL TO ATTEND YOUR APPOINTMENT OR LESS THAN 24 HOURS NOTICE OF CANCELLATION IS GIVEN.