New Patient Form

Patient details

TITLE*

FIRST NAME

LAST NAME*

DATE OF BIRTH*

GENDER

OCCUPATION

Parent/Guardian Details

Is the patient under 18 years?

Yes

PARENT #1

RELATIONSHIP #1

PHONE #1

PARENT #2

RELATIONSHIP #2

PHONE #2

PREFERRED/OTHER CONTACT

RELATIONSHIP #3

PHONE #3

Contact Details

HOME PHONE*

MOBILE*

EMAIL*

STREET ADDRESS*

SUBURB*

POSTCODE*

Is your postal address different from above?

Yes

POSTAL ADDRESS

POSTAL SUBURB

POST CODE

Who's covering your visit?

Dental Benefit Fund (Extras)

Person/Third Party Responsible for payment of your account

Emergency Details

EMERGENCY CONTACT*

RELATIONSHIP*

EMERGENCY NUMBER*

MEDICAL DOCTOR

MEDICAL PHONE

OTHER SPECIALIST

Referring Dentist

Dentist Location

Do you see any other Dentists or Dental Specialists?

Medical Questionnaire

Please indicate by ticking the appropriate boxes if you have ever been diagnosed with, have been, or are currently suffering from one of the following conditions:

Medical Conditions

Artificial Joints

High Blood Pressure

Low Blood Pressure

Heart Problems

Prosthetic Valves or Stents

Pacemaker

Bacterial Endocarditis

Stroke

Medical Conditions

Cancer or Growths

Excessive Bleeding (inc Blood Thinners)

HIV

Bone Disorders (eg. Osteoporosis)

Respiratory Problems

Asthma

Sleep Apnoea

Sinus Problems

Medical Conditions

Previous Radiation Treatment

Kidney Disease

Thyroid Problems

Stomach Problems (eg. Ulcers, Reflux)

Nervous Disorders

Epilepsy

Diabetes

Liver Disease (inc. Hepatitis)

Medical Questionnaire

Do you have any allergies, or other medical conditions we need to be aware of?

Allergies

Allergy Details

Is there any other information that should be known about your health?

Please list all medications, prescribed or otherwise, that you take routinely or at present:

Medical History

Have you had any problems with dental treatment in the past?

Have you had any problems with dental treatment in the past?*

Yes

No

Previous Dental Experience

Are you pregnant?

Are you pregnant?*

Yes

No

Pregnancy details

Have you been admitted to hospital or needed emergency care in the past 12 months?

Have you been admitted to hospital or needed emergency care in the past 12 months?*

Yes

No

Hospital Admission details

Medical History

Are you currently undergoing any medical investigations?

Are you currently undergoing any medical investigations?*

Yes

No

Medical investigation Details

Is there any issue that you would like to discuss with the dentist in private?

Yes

No

Other issues

Consent

To the best of my knowledge, all answers to the preceding questions are correct. I understand that it is my duty to inform the dentist should any of my medical circumstances change. I have read the Privacy Policy .

Dated

Adelaide Endodontic Specialists

New Patient Form

Patient details

Parent/Guardian Details

Contact Details

Who's covering your visit?

Emergency Details

Referring Dentist

Medical Questionnaire

Medical Questionnaire

Medical History

Medical History

Consent

Adelaide Endodontic Specialists

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