Medical History Questionnaire

First name*

Surname*

Preferred Name

Date of Birth*

Parents Name (IF UNDER 18)

Address

Mobile*

Best Phone

Alternative Phone Contact

Name

Email Address*

Occupation

Name of Employer

Next of Kin

Phone*

How Did You Find About Us?

Do You Have Dental Health Insurance Cover?

Yes

Fund Name

How Long Since your last dental appointment?

How offen do you have dental examinations?

Previous Dental RadioGraphs were taken :

Less than 12 months

Between 12 & 24 Months

Unsure

Purpose of visit

Discoloured teeth

Crooked teeth

Missing teeth

Unsatisfactory restorations

Pain or discomfort (please give more information below)

Unsatisfactory dentures

Other

Have you ever had a reaction to a dental injection?

Yes

other concerns :

Tooth-coloured material only

High aesthetic ceramic restorations

No preference

Wish to discuss

medical practitioner

phone

address

Allergies

How Many Years You Smoked?

How many a day

1-10 11-20 20+

Possibly pregnant

Yes

Due Date

Are you currently taking any medications?

Yes

Medications List

Please read and accept below terms.

Thank you for completing our online form, Once you hit the Submit button this information would be transferred to our practice.

A copy of the information given will be sent to your email.

Please check your email after submitting the form, you should get a copy of Patient Registration Forms – 4 pages (as PDF attachment). If convenient, please print this document, sign where indicated at the bottom of pages 3 and 4 and return to us via email info@ashtonavenuedental.com.au . If you are unable to print this document we are happy to print this off for you to sign before your appointment.

Monday/Wednesday/Friday	9.00AM TO 5.00PM
Tuesday/Thursday	9.00AM TO 7.00PM
Saturday	9.00AM TO 1.00PM
Sunday	Closed

Working Time

Emergency Case