Confidential Medical History

Your details

Name(Required)

Prefix First Last

Hidden

Your prefix

Date of Birth(Required)

Parent or Guardian

Required if patient is younger than 18.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Contact preference

Phone/Text

Occupation

How did you hear about us?

Google search

Social Media

Other Advertising

From family or friend

Other

Other, please specify

Who recommended us?

We like to thank those who refer. If someone recommended us, please let us know so we can send them a present!

Doctors Information

Name of your Doctor

Practice Name

Practice Phone

Emergency Information

Emergency Contact

Relationship

Emergency Contact Phone

Medical Health Assessment

Tick the boxes if you suffer from any of the following conditions

Heart(Required)

Rheumatic Fever

Heart Murmur

High Blood Pressure

Angina

Heart Surgery

Thrombosis

Pacemaker Fitted

Other Heart condition

None

Heart – Please provide any relevant details and medication

Blood(Required)

Hepatitis B

Anaemia

H.I.V.

Sickle Cell

Abnormal Blood Test Result

Blood refused by transfusion service

Other Blood condition

None

Blood – Please provide any relevant details and medication

Allergies / Reactions(Required)

Allergies / Reactions – Please provide any relevant details and medication

Chest / Lungs(Required)

COPD

Asthma

Other Chest Condition

None

Chest – Please provide any relevant details and medication

Other Diseases

Other – Please provide any relevant details and medication

Warnings / Anything else(Required)

Warnings – Please provide any relevant details and 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 tobacco products (Quantity per day)

High sugar (Frequency)

Fizzy/acidic/sugary drinks (Quantity per day)

Other (Please specify)

Other habits, please specify

Confidential Oral Health Survey

What is the purpose of your visit?

Who was your previous dentist?

Have you ever experienced dental anxiety?

Please tell us about your oral health. Tick any of the statements below that apply to you.

Appearance

I feel self-conscious when I smile.

I am dissatisfied with the appearance of my teeth.

I have whitened (bleached) my teeth in the past.

I have irregularly positioned (crooked or spaced) teeth that I dislike.

I have chips or gaps in my teeth that worry me.

I have missing teeth that concern me.

Gum and Bones

My gums appear red and swollen, or bleed and are painful when brushed or flossed.

I have been treated for gum disease or been told I have lost bone around my teeth.

I have noticed an unpleasant taste or odour in my mouth.

I have noticed my gums have started receding.

I have noticed my teeth are starting to become loose and I have difficulty chewing hard foods.

There is a history or periodontal (gum) disease in my family.

Bite and Jaw Joint

I have problems with my jaw joint (pain, sounds, limited opening, locking).

I have problems chewing gum.

I have problems chewing hard foods.

My teeth have changed (become shorter, thinner, warn) in the last 5 years.

I have more than one bite position and squeeze to make my teeth fit together.

I bite my nails or cheek, use teeth to hold objects, or have other oral habits.

I clench my teeth in the daytime and they become sore.

I have problems sleeping or wake with an awareness of my teeth.

I have/do wear a bite appliance at night to protect my teeth.

Tooth Structure

If you could change your smile, what would you most like to change?

Information

I would like my dentist to send me information relating to the answers I have given.

I would like to be contacted about important notifications

I would like to receive practice newsletters (approximately on per two months)

I would like to receive information about products & service or promotions.

I agree to the privacy policy.

Fourpeaks Dental 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.

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.

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