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Suite 1, 20 Lake Orr Drive, Varsity Lakes, QLD 4227

DENTAL AND MEDICAL HISTORY IN CONFIDENCE

I would like to welcome you to my practice. This questionnaire is confidential and filling out this form helps us provide the best possible care and treatment for you. To optimise your treatment time, please complete and submit this form at least one week prior to your appointment.

Please arrive 15 minutes earlier than the scheduled appointment time to allow for pre-treatment administration.

ANTIBIOTICS: If your medical practitioner or medical specialist advised you that your medical condition or joint replacement requires antibiotic coverage prior to dental appointments, then they must be taken prior to a periodontal consultation and or treatment. If the antibiotics were not taken as advised then the examination cannot occur.

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      Personal Details

    • 2

      Emergency Contact

    • 3

      Referring Dentist

    • 4

      Health Cover

    • 5

      Dental Studies Waiver

    • 6

      About Your Appointment

    • 7

      Suffer Any Problems

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      Happy with your Appearance?

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      Medical History

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    Personal Details

    Personal Details

    If you are deaf, hard of hearing or speech-impaired and need assistance, Please let our friendly team know when booking an appointment. To ensure staff are confident they are effectively communicating with you, we may request that you contact an accredited interpreter to assist with your appointment. If you need assistance locating an interpreter for your appointment https://www.qits.com.au/ may be able to help.

    Emergency Contact

    Referring Dentist



    Please provide your regular or last visited dentist's information below.

    Please provide your regular or last visited dentist's information below.

    Health Cover

    Dental Studies Waiver

    As a dental specialist, I am involved in educational lectures or research, which sometimes require treatment records of my patients. All records such as X-rays and photos are used anonymously.

    About Your Appointment

    Do you suffer from any of the following problems?

    Are you happy with the appearance of your:

    Medical History

    Please be aware that if you have been advised to take antibiotics prior to dental appointment, then you must take them prior to a consultation by a periodontist. If not the examination can not occur.

    To add additional medications please click on the + icon, which will add a new line.

    To add additional medications please click on the + icon, which will add a new line.

    Do you have or have you ever had any of the following conditions?

    To add additional information please click on the + icon, which will add a new line.

    To add additional information please click on the + icon, which will add a new line.

    To add additional information please click on the + icon, which will add a new line.

    To add additional information please click on the + icon, which will add a new line.

    To add additional information please click on the + icon, which will add a new line.

    To add additional information please click on the + icon, which will add a new line.

    To add additional information please click on the + icon, which will add a new line.

    By submitting this form you are agreeing to the following terms and conditions:

    I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all the questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider, who may release such information to you. I will notify you of any changes in my health or medication.

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