Medical History Thank you for booking in an appointment. Could you please take a few moments to fill in your medical history on the form below. TitleMrMrsMsDrMissMasterPatient Surname:*Patient First Name:*Spouse Name:Parent/Guardian Name (minors only):Address:*Postcode:*Home Phone:Mobile:*Patient’s Date of Birth:* Occupation:*Email address:*How did you hear about us? Your answer will provide us with much appreciated data.Internet Search Engine. (which one eg yahoo, google etc)Advertising. Yellow Pages or other?Referred by family or friend. If so who?Other? Details*Are you in a Private Health Fund?YesNoWhich One:*Are you a Veteran Affairs Patient?YesNoDVA Card Number:*Are you currently being treated by your doctor?YesNoDetails:Name of Doctor:Dr’s Phone No:Are you taking ANY kind of medication or supplements at present, including aspirin or nurofen.Details:*Have you been hospitalised in the past 2 years?YesNoDetails:*Has your Dr ever advised you to have antibiotic cover prior to dental treatment?YesNoIf so why?Please list any medication you are allergic to..ie. penicillin, sulphur etc.Do you have any other allergies that we should know about?Ladies - Is there any possibility you may be pregnant at the moment?Please TICK any of the below that apply to you. Rheumatic Fever Prosthetic Implant Diabetes Thyroid Complaint Kidney Disease Excessive Bleeding Heart Valve disorder Nervous Condition Tuberculosis Stroke Anaemia Smoker Epilepsy Asthma High BP Contact with HIV/AIDS virus Hepatitis Heart Complaint Pacemaker Any other condition:Please rest assured that your dental team are professionals. All information contained on your medical history will be kept in the strictest confidence.SignatureSignatureOr Signature of Parent/Guardian:Or Signature of Parent/Guardian:Today’s Date:* Please advise your dental team if there are ANY changes to your medical history EACH time you visit THIS CLINIC DOES NOT OPERATE AN ACCOUNT SYSTEM. FULL PAYMENT IS TO BE MADE AT THE COMPLETION OF EACH VISIT. NO EXCEPTIONS. This iframe contains the logic required to handle AJAX powered Gravity Forms.