Welcome to the Maroubra Dental Centre please fill in the acquaintance form and submit.
How would you like to be contacted to notify you are due for a check up and clean?
Please tick appropriate:
Home phMobileWork phMail
Do you have Health Insurance for dental treatment? YesNo
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Referred By:
Please SelectYellow PagesInternet SearchShop FrontAnother patient/friendOther
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Details of person to contact in an emergency:
Medical History
Are you receiving any medical treatment at the present time? YesNo
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Have you been a patient in hospital during the past two years? YesNo
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Have you taken any medicine tablets, capsules or drugs during the past two years? YesNo
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Have you experienced any allergies or unusual effects from: tablets, drugs, injections or anaesthetic? YesNo
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Are you, or have you been, under the care of a doctor during the past two years? YesNo
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Do you smoke? YesNo
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Have you ever had or have any of the following? If so, please tick as appropriate
Heart TroubleAsthmaHepatitis – Type A, B or CDepressive IllnessEpilepsyKidney TroubleAnaemiaDrug DependenceDiabetesHigh Blood PressureBronchitis/Chest ProblemsArthritisOsteoporosisSevere HeadachesGastric ProblemsCold SoresRheumatic Fever
Have you had any prosthetic surgery? If yes, when? (E.g. Heart Valve, Hip Replacement, Knee Replacement etc) YesNo
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Women Only: Are you pregnant? YesNo
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Dental History
Do you have Dental pain or a Dental problem at present? YesNo
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Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches? YesNo
Do you become anxious or uncomfortable when you are having dental treatment? YesNo
I acknowledge that I am responsible for all costs of treatment incurred. Payment for treatment is due on the day of treatment.
Signed* : Patient/Parent/Guardian
