Confidential Medical History Update Your Details Prefix Mr. Mrs. Miss Ms. Dr. First Name * Surname * Date of Birth * Email * Mobile Address - only if changed since last visit Street Address Town/City Postcode Parent or Guardian Doctors Information - only if changed since last visit Name of Doctor Practice name Practice phone Emergency Information - only if changed since last visit Emergency Contact Emergency Contact Phone Relationship Medical Health Assessment Heart * Rheumatic Fever Heart Murmur High Blood Pressure Angina Heart Surgery Thrombosis Pacemaker Fitted Other Heart condition None Details Blood * Hepatitis B Anaemia H.I.V. Sickle Cell Abnormal Blood Test Result Blood refused by transfusion service Other Blood condition None If yes, details/medication Allergies / Reactions * Penicillin Eczema Aspirin Latex Anti-Tetanus Serum Plants Medicines Foods Reaction to General Anaesthetic Hay Fever Reaction to Local Anaesthetic Other Allergy None Details Chest * COPD Asthma Other Chest Condition None If yes, details/medication Warnings * Pregnant or possibly pregnant Problem being reclined Antibiotic Cover required Steroids in last 2 years Warning Card/Bracelet Anything else your dentist should know Bruising or persistent bleeding after injury, surgery or tooth extraction Currently under treatment of a doctor, hospital or clinic Any other treatment that required you to be hospitalised None Details Other * Liver Disease (e.g. jaundice) Kidney Disease Diabetes / Family with Diabetes Epilepsy Acid Reflux or Eating disorder Bone or Joint disease Cancer Artificial Joint Fainting Attacks or Blackouts Giddiness - Vertigo None If yes, details/medication Medication List and state doses for any prescribed medicines, tablets, ointments, injections, inhalers (inc. contraceptives and HRT) or recreational drugs you are taking that have not already been listed: Habits Smoke / Vape tobacco products (Per day) High sugar / Frequency Fizzy / acidic / sugary drinks Details Consent * I confirm that the information above is true and correct to the best of my knowledge Privacy Policy * Our Practice follows the rules set out below whenever we collect, use, store or disclose information about your health. Collecting your health information – When we collect health information from you we will... - Only collect the information for the purpose of treating you (or for some related purpose) - Collect information directly from you unless you have authorised us to collect the information from someone else (or we have some other lawful reason for collecting the information from someone else); and - Tell you why we are collecting the information and what we will do with it. Using your health information – We will not use your health information for any purpose other than for the purpose of treating you unless we get your consent or we will use your information in a way that doesn’t identify you (or where we have some lawful reason for doing so). Storing your information – We will store your health information securely so that only authorised people can access or use your information. Disclosing your health information – We will not disclose your health information to anyone without your consent unless we have a lawful reason for doing so. Access and correction of your health information – You can ask us to confirm whether we hold information about you. If we hold information about you, you have the right to access the information. You can ask us to correct any information that we hold about you if you think that the information is inaccurate. If we refuse to correct your information, you can ask us to put a note on your information that states that you have asked for the correction to be made. Enquiries – If you have any concerns about any matter relating to your health information, please ask to speak to our privacy officer. I agree to the privacy policy. Payment Please note that payment is required at the time of treatment. All cost in relation to collection of overdue accounts will be added to your account. Appointments not kept, failed, or cancelled without 48 hours’ notice may incur a charge. We gladly accept EFTPOS, Visa, MasterCard, and Q-Card. We can also process payments through Southern Cross Easy-Claim for those with dental cover. Appointment Changes 24 hours notice is required for appointment changes. Missed appointments or short notice cancelations may attract a fee. Thank you for completing the form.
