Medical questionnaire: annual update

First Name/s*

Last Name*

Date of Birth*

Address

Please complete to advise if you have moved residential address in the last 12-24 months. If not, simply move onto next question and we will apply your address previously provided.

Street Address Address Line 2 City State Post Code

Postal Address

Same as above

Postal Address

Street Address Address Line 2 City State Post Code

Home Telephone

Mobile Telephone*

Email Address*

Preferred method of appointment confirmations*

How would you like us to contact you to confirm appointment times?

Emergency Contact Name*

Emergency Contact Number*

Health Insurance*

What health fund are you with for "Extras Cover" that entitles you to claim rebates for allied healthcare services.

Are you interested in changing the overall look of your smile with cosmetic dental options?

Yes, please tell me more about a Smile makeover
No thank you, I just want healthy teeth
Not sure, what are my options?

Medical History

It is important that we have the most up to date information about your medical history and health status. Please complete the following information statement to indicate if any changes have occurred to your health over the past 1-2 years.

Is your doctor treating you at present?*

Yes
No

Details

What medical condition is your GP doctor currently treating you for or observing?

Are you currently taking any tablets or medicines?*

Yes
No

Details

Please list all medications that you take regularly including vitamin supplements and over the counter products for your health.

Do you take any blood thinners?

Yes
No

Have you been a hospital patient in the past 2 years?*

Yes
No

Details

Reason for why you were hospitalised?

Do you normally require antibiotic cover before dental treatment?*

Yes
No
Unsure

Antibiotics before dental treatment is recommended for: - some people who suffer from specific medical and heart conditions to prevent Infective Endocarditis, and/or - those who have had joint replacement surgeries within the last 3 months such as (hip or knee) to prevent Bacteraemia infections.

Details

Do you smoke?*

Yes
No

Have you ever received any dermal therapies such as botox, dermal fillers or similar products for your facial skin?

Yes
No

Who is your medical practitioner?*

Phone

Any known ALLERGIES?

Please list anything that you are allergic to including though not limited to; drugs, medicines, foods, latex etc.

Please tick any of the following medical conditions that have ever applied to you*

Details of any other medical conditions

If pregnant, when are you due?

Please list any problems or medical complications you have had with previous dental treatment

Feedback

At Smile Central, we strive to provide you with the most comfortable dental experiences possible. Over the years you have been visiting us, we are genuinely interested to hear any feedback you may have about the level of care and service that has been provided.

What have you enjoyed the most about visiting us here at Smile Central?

Would you be happy to write us an review online?

Sharing your positive experiences with others is the best compliment you can give. Our business exists largely by word of mouth referrals in the local community. Visit our Facebook or Google pages to write a review.

Generally, I have been happy with the level of care I receive from the dentist, Dr Chris Lauf.

Generally, I have been happy with the level of care and preventative information that the hygienist provides me.

Generally, I have been happy with the level of care that the Oral Health Therapist provides to my child.

Please comment on your feedback further for us to consider

I have completed this form to the best of my knowledge and acknowledge that this information is an accurate account of my medical history. I understand that failure to do so many compromise my health. On future visits I will advise the dental practitioner of any changes.

Date

Signature*

(Parent/Guardian if under 18 years)

Thank you for taking a few moments to complete this form.

To ensure your health and wellbeing is accurately cared for, we will request and remind you to update this information on an annual basis.

Phone

This field is for validation purposes and should be left unchanged.

Monday	8:30am to 5:00pm
Tuesday	8:30am to 6:30pm
Wednesday	8:30am to 5:00pm
Thursday	8:30am to 8:00pm
Friday	9:00am to 4:00pm

"Let food be thy medicine and medicine by thy food"

Medical questionnaire: annual update

Smile Central: update personal details

Medical History

Feedback

I have completed this form to the best of my knowledge and acknowledge that this information is an accurate account of my medical history. I understand that failure to do so many compromise my health. On future visits I will advise the dental practitioner of any changes.

Thank you for taking a few moments to complete this form.

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