For any first visit to Clarence Dental Centre, we require your personal details and medical history.

  • Please either print the PDF form, and bring the filled form in with you to your appointment
  • Or  fill in online form below.

Download – Personal Information and Medical History Form

 Online Form

Personal Details

Your Email (required)

Title

Surname

First Names

Date of Birth

Gender
MaleFemale

Address

Postcode

Home Telephone

Mobile

Work

Next of Kin (name and phone)

Are you happy to receive SMS messages on your mobile phone to confirm future appointments?
YesNo

Occupation

Account to (if other than self)

Do you belong to a private health fund?
YesNo

Which one?

How were you referred to this practice??
Personal referralInternet searchSchool visit/advertistingWalking/Driving pastFlyerOther

If referred, who referred you to this practice?

If Other, Please specify

 

Medical History

A response to each of the following questions will enable us to provide you with the best oral health care.

Do you have or have you previously had: (please choose yes or no)

Heart Disease Excessive bleeding following surgery or extractions
Rheumatic fever Teeth or jaws broken in accidents
Heart Murmur Radiotherapy for cancer to head or neck
Diabetes Do you have an infectious disease
Abnormal Blood pressure Have you had an illness requiring a blood transfusion
Nervous disorders Do you smoke cigarettes
Asthma Do you have any allergies
Epilepsy Are you pregnant
Thyroid disease Are you presently being treated by a doctor
Hepatitis Stroke / CVA

 
If you have any allergies, please specify

Is there any subject you would like to discuss with the dentist in private?
YesNo

List all medications you are currently taking

Regular medical practitioner name & address

Patient's Acceptance that all information on this form is true

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