Patient Info

New Patient Form

Please complete and submit our Medical History Questionnaire form before your next visit to Thompson Road Dental Services

Online New Patient Form

Online New Patient Form

Online New Patient Form

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Welcome to Thompson Road Dental Services. It is important to know details about your medical history as these could affect the success of your dental treatment and how we can provide this treatment safely for you. The information you provide is treated in the strictest confidence, in accordance with the Privacy Amendment Act.

Please Select  :  
MrMrsMsMissMasterDr

Surname*:

First Name*:

Preferred Name:

Date Of Birth:

Address:

Suburb:

Postcode:

Home Phone:

Mobile:

Work:

Email address*:

Vets Affairs Gold / White

Vets Affairs Card Number:

Expiry:

Do you have private health insurance?
YESNO

Name of Insurance Company

Occupation:

Employer Name:

Next of Kin/Emergency Contact


Name:

Relationship:

Phone:

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MEDICAL HISTORY

Are you currently receiving any medical treatment? if so, please elaborate.

Have you been a patient in hospital during the past 12 months?

Are you taking any medications?
YESNO

Please list current medication(s)

Do you drink alcohol?
YESNO

How many glasses per day

Do you have any allergies, including unusual effects from any medication or anaesthetic?

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Have you had or are you suffering from any of these? (please tick)   
Cardiac Pacemaker
Irregular heartbeatHeart Valve ProblemHeart attack/anginaStrokeHigh blood pressure
Low blood pressureCancerAsthmaOther lung diseaseOsteoporosisDiabetes
Hepatitis
Rheumatic Fever
Arthritis
Thyroid DiseaseEpilepsy
Sleep Apnoea
HIV/AIDS
Nervous Disorders
Liver or kidney disease
Stomach or digestive condition/refluxAre you or could you be pregnantRadiation or chemotherapyEating disorder
Prosthetic implant/joint replacementOrgan or bone marrow transplant
Steroid therapy


Other (specify)

Do you Smoke?
YESNO

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Please tick any dental concerns you have?  
General dental healthBraces/ crooked teethToothacheSensitive Teeth
Bleeding gumsLoose teethBad breathDry mouthMissing teethUnsatisfactory dentureRapidly decaying teethLost filling/cavityGrinding/clenching teethWorn, broken teethSnoring/ Sleep ApnoeaPain in face or jaw jointsDifficulty chewingDiscoloured teethAppearance of teethDental Implants

Other

Are you happy with your smile?
YESNO

If No, why?

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How did you hear about our practice?
Google AdFacebook AdGoogle MapGoogle ListingHealthengineWhite CoatSignageYellow PagesFlyerOther

Referred by a friend?
YESNO

Friend's Name?

Who is your general practitioner?

Telephone:

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed upon by me, to be carried out by the dentist and I assume full financial responsibility for said treatment.I acknowledge Thompson Road Dental Services requires 24 hours notice on cancellations, otherwise a fee will be charged to my account.

Patient Name:

Date:
(Parent or Guardian to sign if patient is a minor)

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