Medical History

Name: Adentica Family Dentists
Address: 17 Mayes Avenue, Caloundra, Q, 4551, Australia
Telephone: (07) 5438 2225

It is important for the Dentist to know details about your medical history as this could affect the success of your dental treatment and how we can provide this treatment safely for you. The information you provide is confidential and will be handled in accordance with our privacy policy which is shown on the reverse of this form.

Personal Details

Title

First Name

Last Name

Preferred Name

Date of Birth

Contact Number (hm)

Contact Number (wk)

Mobile

Occupation

Email address We'll never share your email with anyone else.

Home Address

Postal Address

Health Fund

Fund Name

Name of emergency contact person

Phone Number

General Practitioner's name

Phone Number

Medical History

Do you Smoke?

Yes

How many per day?

Are you pregnant?

Yes

How many months?

Existing Conditions

Dental History

Approximate date of last dental visit

Name of last Dentist

Do you currently have dental pain?

Do you become anxious when having dental treatment?

How did you hear about us?

Word of Mouth

Signage

Internet Search

If a patient or friend referred you, please include their name so we can thank them

Patient Rights and Responsibilites

I have read and accept the patient's rights and responsibilities

Yes

Contact

info@adentica.com.au

(07) 5438 2225

Address

17 Mayes Avenue
Caloundra Q 4551

Hours
Monday – Friday 7.30am - 5pm
Wednesday 7.30am - 6pm

Medical History

Do you have, or have you ever had any of the following medical conditions?If so please tick as appropriate

Do you have, or have you ever had any of the following medical conditions?
If so please tick as appropriate