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
Referred By:
Please SelectYellow PagesInternet SearchShop FrontAnother patient/friendOther
Details of person to contact in an emergency:
Medical History
Are you receiving any medical treatment at the present time? YesNo
Have you been a patient in hospital during the past two years? YesNo
Have you taken any medicine tablets, capsules or drugs during the past two years? YesNo
Have you experienced any allergies or unusual effects from: tablets, drugs, injections or anaesthetic? YesNo
Are you, or have you been, under the care of a doctor during the past two years? YesNo
Do you smoke? YesNo
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
Women Only: Are you pregnant? YesNo
Dental History
Do you have Dental pain or a Dental problem at present? YesNo
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
