Patient History Form

PATIENT HISTORY FORM

Welcome to Tower Dental. Please complete the following medical history form. If you have any questions, please feel free to ask any of our friendly staff. All records are private and confidential.

Medical History

Please tick the appropriate box: (only tick what applies — leave the rest blank)

No of Smokes (per day)		Pregnancy or possibly pregnant	Yes
Diabetic	Yes	How Many Weeks Pregnant
Bruising or persistent bleeding	Yes	Antibiotic Cover required	Yes
Hearing / Sight Impairment (please circle)	Yes	Do not recline	Yes
Recent hospitalisation	Yes	Hepatitis A, B, C or D (please specify)
Rheumatic Fever	Yes	Thrombosis	Yes
High Blood Pressure	Yes	Asthmatic	Yes
Low Blood Pressure	Yes	Anaemia	Yes
Heart Surgery	Yes	Haemophilia	Yes
Pacemaker Fitted	Yes	HIV	Yes
Heart Murmur	Yes	Chest Surgery	Yes
Bronchitis	Yes	Emphysema	Yes
Other:

Allergies: (only tick what applies — leave the rest blank)

Penicillin	Yes	Latex Allergy	Yes
Hay Fever	Yes	Medicines	Yes
Local Anaesthetic	Yes	Plants	Yes
Foods	Yes	Foods	Yes
Aspirin	Yes	Other allergy conditions

GP Information

Dental History

Payment Policy

It is the policy of Tower Dental that all patients settle their accounts in full after each appointment. We accept cash, credit cards and Eftpos. Health insurance claims can be made electronically at reception. In the event that you forget to bring your health insurance card to your appointment, we will request payment in full. Should this occur it is your responsibility to present your invoice and receipt to your Health Fund for processing/refund.

I have completed this questionnaire to the best of my knowledge and understand the payment policy. I acknowledge that failure to make a full health disclosure may place me at undue medical risk.