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Emergency Dental Services
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Date of Birth
Preferred Daytime Contact:
Emergency Contact Phone Number
Name of person responsible for payment of accounts
Which Health Fund do you belong to?
Whom may we thank for recommending you to our practice?
The state of your health may have a very significant effect on your dental care. Please answer these questions fully or discuss them with your dentist:
I have private and confidential medical matters which I wish to discuss with the dentist
Are you receiving any medical treatment at present?
Name of your medical practitioner / specialist
Have you ever been in hospital?
What was the nature of hospitalisation and dates:
Some medicines may interfere with your dental treatment or react with treatments used by your dentist. It is important that your dentist knows precisely what medications (if any) that you are taking. This should include:
If you are in any doubt about your medication, please bring the bottle or packet(s) to the practice to show the dentist.
Warfarin or heparin or other blood thinning medicine
Hormone Replacement Therapy
Cortisone or steroids
Medication for depression (MAOls, SSRls, SNRls or Tricyclics)
Treatment for osteoporosis (bisphosphonates, Prolia)
Any other prescription medication
Any herbal or naturopathic medications
Any 'over the counter' medications
Please provide details (including dose and frequency) of any medicine or medication that you are currently taking, or have been taking recently.
Have EVER had any of the following health conditions? Is so please check the box to indicate which conditions you have experienced.
Any heart (cardiac) complaint/treatment
Heart valve replacement
High or low blood pressure
Anti-coagulant (blood thinning)
Excessive bruising or bleeding
Osteoporosis or low bone density
Diabetes or family history of diabetes
Hepatitis, jaundice or liver disease
Urinary tract/Kidney disease
Joint replacement surgery
Jaw, neck or shoulder injury or pain
Thyroid disease (including goitre)
Nervous system disorder
Gastroesophageal reflux disease (GORD)
Inflammatory bowel disease
Treatment for cancer (type/region)
Allergy or reaction to any medicine (including Penicillin or other antibiotic)
Allergy to any foods, chemical or substance (such as chlorine/latex/antiseptics/elastoplast)
Transplanted organ/bone marrow/stem cells
Have you ever smoked?
Approximate date of quitting
Do you currently smoke?
For how long have you smoked and how much do you smoke per day?
Have you ever used illicit substances?
Have you ever required any treatment for smoking related diseases or conditions?
Do you suffer from any illness not listed above or carry any infectious disease?
If yes, please provide details
Are you Female?
Are you pregnant?
If yes, when are you due?
Are you breastfeeding?
Do you acknowledge that the information provided accurately represents your medical history.
I will advise my dentist of any changes to my medical history in the future
I understand that all medical details will be treated with complete professional confidentiality
(Parent or guardian if under 18 years) Typing your name below acts as a digital representation of your signature.