Moonee Ponds Periodontic & Implant Centre| Patient Info

Medical history

Welcome to our practice! Your health is an important factor in determining your treatment. To assist in establishing a diagnosis and treatment plan, please answer the following questions as accurately as possible. All information collected remains within the practice and will be held in confidence according to our privacy policy.

Title

Firstname

Surname

Preferred name

Date of birth

Address

Suburb

Home phone

Mobile

Occupation

General dentist

Do you have private health insurance with dental cover? YesNo

If yes: Fund

Membership #

Patient #

Medicare #

Patient #

Valid to

Medications It is important to list all medications you are taking. This includes all oral medications and regular injections. Please list all medications including injections.

Who referred you to this office (if different from general dentist)?

Are you happy to receive correspondence by email? YesNo

Would you like to receive reminders by SMS? YesNo

Medical information ( Confidential)

Cancer : Type

Do you smoke? YesNo

How many per day:

Are you pregnant? YesNo

How many weeks:

Are you a blood donor? YesNo

Do you have any allergies? If so, what are they:

Consent to treatment

1. I hereby authorize the periodontist or trained staff to take x-rays, photographs or other diagnostic aids deemed appropriate by the periodontist to make a thorough diagnosis. Photographs may be used for teaching purposes.

2. I agree that the above is a true and accurate record. I understand that Moonee Ponds Periodontics & implant Centre requires payment on the day of treatment. Any expenses, costs or disbursements incurred by Moonee Ponds Periodontics & Implant Centre in recovering outstanding monies including debt collection fees and solicitor costs shall be paid by the responsible party above. I further acknowledge that failure to attend any appointment without notice may also require a deposit prior to scheduling any future appointments.

Please Note: The medical history form will be electronically copied to your file and the original will be subsequently destroyed. By signing this document, you agree to this process. This form is a guide only and you should discuss any relevant matters with your periodontist prior to the commencement of any dental treatments.

Date

By submitting this form, I accept that the information entered will be used within the strict framework of my request* Checkbox mandatory

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Tresmere trading Moonee Ponds Periodontic & Implant Centre is committed to ensuring that the collection and processing of data carried out by our mooneepondsperiodontics.com site complies with the General Data Protection Regulations (GDPR) and the Data Protection Act. To know and exercise your rights, particularly concerning the withdrawal of consent to the use of collected data, please consult our privacy policy

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