Patient form

Patient information

Preferred title

First name

Last name

Age

Date of birth

Sex

Male

Female

Non binary

Home phone

Mobile phone

Email

Address

City / Suburb

State

Postcode

Person responsible for accounts:

Name

Relation

Home phone

Work phone

Mobile phone

Address

City / Suburb

State

Postcode

Do you have Private Health Insurance?

No

Yes

Dental Fund

Ref. Number

Medicare Number

Pt#

Expiry date

Name(s) of other family member(s) treated by us

Patient’s school or workplace

Patient referred by

General Dentist

For child/adolescent patients only

Mother’s name

Occupation

Phone

Father’s name

Occupation

Phone

Parents are

Married

Single

Separated/Divorced

Widowed

Patient Medical and Dental History

Please (x) any of these conditions that the patient has had:

If yes to any of the above please give details

What medication is the patient taking?

What dental treatment has the patient had?

Were there any difficulties with treatment?

Have any teeth been extracted?

Have there been any accidents involving the teeth or jaws?

Has the patient had orthodontic treatment before?

Is the patient now

growing rapidly

growing moderately

stopped growing

Women, are you pregnant?

Yes

No

Does the patient smoke?

Yes

No

Does the patient drink alcohol regularly?

Yes

No

I would like to discuss the above questions in private

Yes

No

Signature

Date

Patient Form

Patient information

Person responsible for accounts:

For child/adolescent patients only

Patient Medical and Dental History