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
TitleMrMrsMsDrMasterMissNo TitleOther
First Name*
Last Name*
Date of Birth*
Preferred Name
Address
Post Code
Mobile Phone*
Home Phone
Email
How would you like to receive an appointment reminder?EmailSMSPhoneMailNone
If you are under the age of 18 please state Father / Mother / Guardian‘s Name
Name of Parent / Guardian
Relationship
Contact No
Occupation
Business Name
Work Phone
Name
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?
Fund
Membership No
Reference No
Are you a Veteran Affairs Card Holder?
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
Name of your Medical Doctor
Medical Doctor Contact No*
Medical Doctor Address
Are you currently being treated for any medical condition?
Do you have, or have you ever suffered from any of the following medical conditions? Please provide the approximate date of diagnosis if possible.
Cardiac / Heart Disease
Stroke
Tuberculosis
Cancer / Leukaemia
High / Low Blood Pressure
High Cholesterol
Respiratory / Lung Disease (Bronchitis, Emphysema)
Prosthetic Body Part / Joints
Others (Please Specify)
Blood / Excessive Bleeding Disorders
Nervous / Anxiety Conditions
Epilepsy
Thyroid Problems
HIV / AIDS
Organ / Bone Marrow Transplant
Sleep Disorders / Apnoea
Allergies / Adverse reactions
Kidney / Urinary Disease
Osteoporosis
Eating Disorders
Rheumatic Fever / Heart Murmur / Artificial Heart Valve
Mental / Psychological Conditions
Stomach / Bowel Problems
Diabetes
Type 1Type 2
Hepatitis
ABCOther
Do you have an allergic or adverse reaction to medication or treatments (ie. Latex, Nickel, Penicillin, Codeine)?
Do you carry medication with you that may be required during treatment or in case of an emergency?
Do you have a neck or back problem that could be affected by your treatment?
Are you currently taking or have recently taken any medication?
Antibiotics
Blood Thinning Medication (ie. Warfrin, Asprin)
Asthma Medications
Anti-inflammatory Medication (ie. Nurofen, Voltaren)
Arthritis Medication
Cancer Medication
Oral Contraceptive Pill
Other Medication
Pain Killers (ie. Panadol, Codeine)
Diabetes Medications
Natural Therapies
Steroid Medication
Osteoporosis / Bisphophonate Medication (ie. Didronel, Fosamax, Aredia, Pamisol, Actonel, Zometa, Bonefos, Skelid, Bonviva)
Pregnant, undergoing fertility treatment or family planning? How many weeks pregnant?
Smoker ?
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