Patient Info and Medical History

    Please kindly provide the following pre-treatment information. The information we collect enables us to provide you with better care. Your privacy is important to us, so all information provided will be kept strictly confidential

    YOUR DETAILS

    TitleMrMrsMsDrMasterMissNo TitleOther

    EmailSMSPhoneMailNone

    If you are under the age of 18 please state Father / Mother / Guardian‘s Name

    BUSINESS CONTACT DETAILS

    EMERGENCY CONTACT DETAILS

    DENTAL INFORMATION

    What is the purpose of your visit today?

    When was your last dental checkup?

    Have you had any problems with past dental treatments?

    NoYes

    If Yes

    Do you have Private Health Insurance?

    NoYes

    Fund

    Membership No

    Reference No

    Are you a Veteran Affairs Card Holder?

    NoYes

    Card No

    How did you hear about this practice?

    To whom shall we make your accounts payable?

    I have read and understand Beyond Smiles Privacy Policy. I understand that payment is required on the day of treatment.

    My preferred method of payment is

    CashCredit CardEFT

    Patient / Guardian Name

    Date

    Medical History

    CONFIDENTIAL HEALTH INFORMATION

    How many per day?