Online Medical Health Form For New Patients | Ipswich Dental Care

15 Gray Street, Ipswich QLD 4305

07 3202 3999

ipswich dental care

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About Us
- Review Our Services
Kids
- Kids Treatment Room
- Free Kids Dental
Services
Before & After
Blog
Health Form
Contact
Online Booking

Health History Form

So we can ensure we are looking after your needs, please review and complete the following questionnaire.

Title: Mr/Mrs/Miss/Ms/Dr:

Surname:

First Name:

Street Address:

Suburb:

Home Phone Number:

Work Phone Number:

Date of Birth:

Email:

Occupation:

Name of person responsible for fees, if not self:

Emergency Contact Name:

Emergency Contact Phone Number:

Emergency Contact Address:

How did you hear about us?

Google Facebook Driving Past Health Fund Personal Reference Other

Purpose of Visit

Dental Insurance Company:

Is another member of your family a patient at our office?

Yes No

Have you had any of the following:

Heart Problems (specify below) Blood Pressure (high/low) Artificial Joints (specify below) Rheumatic Fever Circulatory Problems Radiation Treatment Excessive Bleeding Excessive Bruising Ulcers (stomach) Sinus Troubles Tumor History Alellergies to Anaesthetics Allergies to Penicillin Allergies to Medications (specify below) Allergies to Latex Anemia or Other Blood Disorders Diabetes Asthma Hepatitis A B C D E Epilepsy Liver or Kidney Problems (specify below) HIV/Aids Are you a Smoker

Other

Have you ever been told that you require antibiotics prior to dental treatment?

Yes No

Are you currently taking any medications?

Yes No

List medications

Are you currently breastfeeding?

Yes No

Would you like us to discuss cosmetic dentistry with you?

Yes No

Have you had any of the following:

Do you feel you grind your teeth? Have you ever had orthodontic treatment? Do you wear a night guard? Have you ever had gum disease? Have you ever had your bite adjusted? Do you bite your lips or cheek often? Does your jaw click or hurt? Do you think you have occasional bad breath? Do your gums ever bleed when you brush them? Do you experience sensitivity with hot/cold? Does floss ever tear between your teeth? Do your teeth ever hurt when you bite hard?

Other Notes:

Name of your GP/Doctor:

GP/Doctors Address:

GP/Doctors Phone Number:

Are you pregnant?

Yes No

When is your due date?

How long since your last dental appointment?

How often do you have dental examinations?

Previous Dental X-Rays Were Taken:

Less than a year ago Longer than a year ago

Are you Aboringinal or Torres Strait Islander

Yes No

Consent for treatment:

I hereby authorise the dentist or designated team to take x-rays, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anaesthetics, sedatives and other medication as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand I can ask for a complete recital of any possible complications. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made.

Trading Hours

Mon – Wed – Fri: 8.30am to 5pm
Tue – Thu : 9am to 8pm
Sat: 8am to 12pm

Address

15 Gray Street,
Ipswich QLD 4305

Phone

07 3202 3999

Quick Links

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Payment Options

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