Medical History Form | Royal Park Dental

Title Title

First Name

Surname

Date of Birth

Home Phone

Work Phone

Mobile Phone

Email

Occupation

Private Dental Cover

Yes

No

Name of Health Fund:

PLEASE TICK BOXES IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING:

PLEASE TICK BOXES IF YOU ARE CONCERNED WITH / INTERESTED IN ANY OF THE FOLLOWING:

Reason for current visit:

Any other relevant conditions:

Any current medication(s):

Are you allergic to any of these?

Penicillin

Latex

Other Allergies:

Do you smoke?

Yes

No

If yes, how many in a day/week/month:

Have you had any X - rays in last 2 years?

Yes

No

When was your last visit to the dentist?

How did you find out about our practice?

Our website/ Google

Our Facebook Page

Walk by/ Drive by

Signage board

Friend/ Relative (Please Name):

I agree to be responsible for payment of all the treatments at the time of the service. Please give 24 HOURS notice for changes to your appointment.*A FEE WILL BE CHARGED FOR NON - ATTENDANCE*

Digital Signature (Full Name):

Date

PAYMENT & CO-PAYMENT ARE DUE AT TIME OF SERVICE
WE ACCEPT ALL CREDIT CARDS, PERSONAL CHEQUES, EFTPOS AND CASH

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