07 3263 1310
758 Robinson Rd W
,
Aspley
QLD
4034
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General Dentistry
Dental Anxiety Management
Dental Check-Up and Clean
Family Dentistry
Fillings, Inlays and Onlays
Crowns and Bridges
Emergency Dentistry
Laser Dentistry
Cosmetic Dentistry
Teeth Whitening
Dental Implants
Smile Makeover
Dental Veneers
Orthodontics
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Invisalign
About Us
Dr Chris Lauf
Our team
Independent Dental Network
Health Fund Guide
Community Engagement
Blog
Oral Health Promotion
Interest Free Payment Options Including AFTERPAY
Special offer
Advanced Technology
Laser Dentistry
Dental Crowns with CEREC
Digital X-Rays and 3D Radiographic Imaging
Pain Free Dental Injections: The Wand
Bite analysis: T-Scan
Custom Sports Mouth Guards
Root Canal Therapy: Precision Microscope
Gallery
Contact Us
Virtual Tour
New patient questionaire
Medical questionnaire: annual update
Smile Central: update personal details
Please complete this web form prior to your appointment. The following information will be remain strictly confidential. Our promise to you is that all data collected will not be shared with any third party without your prior informed consent such as referral to medical specialist and remains confidential. All fields marked
*
are required.
First Name/s
*
Last Name
*
Date of Birth
*
Date Format: DD slash MM slash YYYY
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
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Post Code
Postal Address
Same as above
Postal Address
Street Address
Address Line 2
City
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
State
Post Code
Home Telephone
Mobile Telephone
*
Email Address
*
Preferred method of appointment confirmations
*
SMS text
Email
Phone call
How would you like us to contact you to confirm appointment times?
Emergency Contact Name
*
Emergency Contact Number
*
Health Insurance
*
No insurance
Medibank Private or AHM
Bupa
Defence Health
nib
hif
Doctors health fund
Westfund
Qld Country
Police Health
CBHS
Teachers Health Fund
Other not specified
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
*
No known medical ailments
Diabetes
Asthma
Osteoporosis
Arthritis
Rheumatic Fever
Dementia/Alzheimer's
Epilepsy
HIV/AIDS virus
Bronchitis
Kidney Disease
Liver Disease
Excessive Bleeding
Heart Complaint
Stroke
Heart Valve Disorder
Cardiac Pacemaker
High Blood Pressure
Low Blood Pressure
Tuberculosis
Hepatitis A or B
Hepatitis C
Thyroid disorder
Autoimmune disorder
Mental Health disorder
Autism spectrum disorder
Chronic Fatigue Syndrome
Cancer
Skin cancer
Growth hormone treatment
Glaucoma
Prosthetic joint or implant
Any other condition
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?
Yes
No
don't know how
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
.
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Generally, I have been happy with the level of care and preventative information that the hygienist provides me.
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Generally, I have been happy with the level of care that the Oral Health Therapist provides to my child.
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
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
Date Format: DD slash MM slash YYYY
Signature
*
(Parent/Guardian if under 18 years)
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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.
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Home
Services
▼
General Dentistry
▼
Dental Anxiety Management
Dental Check-Up and Clean
Family Dentistry
Fillings, Inlays and Onlays
Crowns and Bridges
Emergency Dentistry
Laser Dentistry
Cosmetic Dentistry
▼
Teeth Whitening
Dental Implants
Smile Makeover
Dental Veneers
Orthodontics
▼
Braces
Invisalign
About Us
▼
Dr Chris Lauf
Our team
Independent Dental Network
▼
Health Fund Guide
Community Engagement
▼
Blog
Oral Health Promotion
Interest Free Payment Options Including AFTERPAY
Special offer
Advanced Technology
▼
Laser Dentistry
Dental Crowns with CEREC
Digital X-Rays and 3D Radiographic Imaging
Pain Free Dental Injections: The Wand
Bite analysis: T-Scan
Custom Sports Mouth Guards
Root Canal Therapy: Precision Microscope
Gallery
Contact Us
▼
Virtual Tour
New patient questionaire
Medical questionnaire: annual update
CALL NOW