DENTAL 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 one week to at least forty-eight hours 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.
Updating Medical History
Treatment of Periodontal ‘gum’ disease.
Placement of dental implants.
Exposure of impacted teeth/ fraenectomies etc.
Functional and Cosmetic ‘gum’ surgery.
Surgical extraction of teeth.
New Patient History
Refer a Patient
Referring a patient to our Practice?
All general enquiries and referrals are kept strictly confidential.
Please use our Client Referral Form for more specific contact with Coastal Periodontics.