Patient Medical History Form

TitleMrMrsMissMasterMsDrOther
Surname
FirstName
Preferred Name
Date of Birth
Address
Postcode
Home Phone
Mobile
Business/Work
Email
I consent to being sentOffersEducational MaterialTreatment Related

Postal Address(if different to address given above)
Emergency Contact Name
Phone
Relationship
Medical Doctor
Medical Phone
Address
Medicare Number
Individual Reference Number (IRN):

Private Health Insurance Details:
Health Fund
Membership Number
IRN

Item numbers on our statement represent as accurately as possible the procedures performed, but in no way are they a claim on anyone other than the patient for whom they were performed. The eligibility of the patient, or the procedures, to attract refunds, and the rates of those refunds, are determined by the conditions of the patient’s health insurance policy. We accept no responsibility, to either party, for any decisions the insurer may make regarding the refund monies to the patient.

Dental Information – for the following questions, please mark (X) your responses to the following questions.

	Yes	No
Do your gums bleed when you brush or floss?	Yes	No
Are your teeth sensitive to cold, hot, sweets or pressure?	Yes	No
Is your mouth dry?	Yes	No
Have you ever had periodontal (gum) treatments?	Yes	No
Have you ever had orthodontic treatment?	Yes	No
Have you had problems associated with previous dental treatment?	Yes	No
Are you currently experiencing dental pain or discomfort?	Yes	No

	Yes	No
Do you have earaches or neck pains?	Yes	No
Do you have any clicking, popping or discomfort in the jaw?	Yes	No
Do you brux or grind your teeth?	Yes	No
Do you have sores or ulcers in your mouth?	Yes	No
Do you wear dentures or partials?	Yes	No
Do you participate in active recreational activities?	Yes	No
Have you ever had a serious injury to your head or mouth?	Yes	No

Date of last dental exam
Date of last dental x-rays?
What was done at the time?
What is the reason for your dental visit today?
How do you feel about your smile?

Medical Information

Have you ever had any of the below medical conditions? Please tick YES or NO to all of the following:

	Yes	No
Stroke	Yes	No
High Blood Pressure	Yes	No
Heart Ailment	Yes	No
Rheumatic Fever	Yes	No
Asthma	Yes	No
Hepatitis (Type A, B, C, D or E)?	Yes	No
AIDS/HIV	Yes	No
Bone Disorder	Yes	No

	Yes	No
Tuberculosis	Yes	No
Bowel Problems	Yes	No
Kidney Disease	Yes	No
Diabetes (Type 1 or Type 2)?	Yes	No
Thyroid Problems	Yes	No
Epilepsy	Yes	No
Blood Disorder	Yes	No

List any other illnesses:
Do you have any allergies?
Are you pregnant?
Do you smoke? If yes, how many times per day?
Do you have anything artificial?
Have you had a serious illness, operation or been hospitalised in the past 5 years? If yes, what was the illness or problem?
Are you taking or have you recently taken any prescription or over the counter medicine(s)? If so please list all, including vitamins, natural or herbal preparations and/or dietary supplements.

How did you find us?Friend
Name
InternetSpecialistOther

Please note: our payment policy is full payment on the day of treatment, and follow up action will be taken to secure all outstanding amounts. If your account is not finalised we will employ a Debt Collection Agency, which will result in additional fees incurred by you.

Cancellation policy: when you book your appointment, you are holding a space on our calendar that is no longer available to our other patients. In order to be respectful of your fellow patients, please call the clinic as soon as you know you will not be able to make your appointment. If cancellation is necessary, we require that you call at least 24 hours in advance or a cancellation fee of $80 will incur. Appointments are in high demand, and your advanced notice will allow another patient access to that appointment time.

I have completed this new patient history form to the best of my knowledge, and understand failure to make a full disclosure may place me at undue medical risk. I understand that notes, radiographs or models relating to my treatment may need to be sent to dental practitioners to aid in my treatment and consent to this. I also give permission for the practice to use the above contact details to send me appointment and check-up reminders.

Signed
Date

Bright Light Dental

We are working to ensure you receive the best treatment.

(03)-9583-0722

(03)-9583-1733

admin@brightlight.com.au

brightlightdental.au

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BrightLight is a multiple award winner

Best Patient Care 2017

Best Practice & Team 2016

Best Patient Care 2014

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