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Skygate Dental Medical History Form

Personal & Emergency Contact Information - Step 1 of 7

Patient Information

Title *

Name *

First

Middle

Last

Date of Birth *//

Address *

Address Line 1

City

State / Province / Region

Postal Code

Contact Number *

Email *

Email

Confirm Email

Occupation

Emergency Contact Information

Emergency Contact Name: *

First

Last

Emergency Contact Relationship: *

Emergency Contact Number: *

Health Fund Information

Do you have a Private Healthfund? *

Yes
No

Please Select Your Fund *

Health Fund Name *

Member Number *

Series Number (Number Next to your Name) *

Child Dental Benefits (CBDS)

If your completing this form as a parent / legal guardian on behalf of your child and they are 17 or younger they may qualify for Child Dental Benefits (CBDS). Please Complete the information below and we will confirm eligibility.

Would you like us to Check CBDS Eligibility? *

Yes
No

Medicare Card Number *

Number Next to Patients Name: *

Full Name of Patient (As Per Medicare Card) *

Medical Information

Any Majory Surgeries / Operations or Illnesses in the last 2 years? *

Yes
No

Surgery / Illness Information *

Date of Surgery *//

Are you taking any Tablets or Medicines (Prescribed or over the counter) at present? *

Yes
No

Please List Any / All Tablets or Medicines (including Prescribed or over the counter) *

Do you have any Abnormal Reactions to Local or General Anaesthesia? *

Yes
No

Additional Information *

Do you Smoke? *

Yes
No

How Many Per Day (Approximately)

Selected Value: 0

Are you Pregnant? *

Yes
No
Unsure

Preexisting Medical Conditions (Please Tick All that Apply) *

None (of the Below)
Steroid Therapy
Rheumatic Fever
Epilepsy
Asthma
Diabetes
Heart Valve Disorder
Stroke
Radiation Therapy
Kidney Disease
Excessive Bleeding
Heart Complaint
Nervous Condition
Tuberculosis
Heart Murmur
Prosthetic Implant
High Blood Pressure
Low Blood Pressure
Cardiac Pacemaker
Stomach or Digestive Condition
Hepatitis or other Liver Disease
Immune Deficiency
Bronchitis, Emphysema or Other Lung Disease
Anemia, Leukemia or Other Blood Disease
Transplanted Organ or Marrow
Other

Additional Conditions / Information *

Have you had any Organ Transplants? *

Yes
No

Organ(s) Transplanted *

Heart
Lung
Kidney
Liver
Other

Additional Information *

Date of Surgery *//

Date of Last Follow up: *//

Name of Surgeon / Specialist *

Contact Number of Surgeon / Specialist *

Have you ever had any Heart Operations / Surgeries? *

Yes
No

Date of Surgery *

Date of Last Follow up: *

Name of Surgeon / Specialist *

Contact Number of Surgeon / Specialist *

Are you Allergic to Any Drugs or Medicines? *

Yes
No

Please List Any Drugs of Medicines you are allergic to: *

Do you have any known Allergies (Including Latex)? *

Yes
No

Please list any known allergies (including Latex): *

Please describe the dental problem(s) you are experiencing: *

Please provide any additional information

Referred By: *

Google
Flyer / Brochure
Walked By
Other

Other Referral *

Privacy Policy / Disclaimer / Payment Policy *

Accept

In order to provide you with the highest standard of dental care, this practice is required to collect personal information from you. This information covers basic details such as your name, address and telephone number but it is also necessary for the dentist to obtain from you details regarding your general health and past medical and surgical events. Without this general health picture, the treating dentist is unable to plan your care properly. Naturally, some of this information is of a personal nature and some of it might be regarded as ‘sensitive’ and not the sort of information that you would wish to be unnecessarily disclosed to others.

We value the need to safeguard this information and, in accordance with the principles laid down in privacy legislation and the guidelines issued by the Australian Dental Association, we would like to assure you that:

This information will only be used by the treating dentist in order to deliver your care to the highest standards.

It will not be disclosed to those not associated with your treatment without your consent except as provided under the legislation and where we consider you would have a reasonable expectation of us to provide such information.

You may seek access to the information held about you and we will provide this access without undue delay. This access might be by inspection of your dental records at the time of appointment or by special access or copying of information at other times.

There will be no charge made for requesting this information but there may be fees levied just to cover the costs associated with the processing of this request or the copying of information.

We will take reasonable steps to ensure at all times that the details we keep about you are accurate, complete and up to date.

We will take reasonable steps to protect this information from misuse or loss and from unauthorized access, modification or disclosure.

Our staff are trained to respect these principles at all times.

PAYMENT POLICY

I verify that all details I have provided in the medical history form on the reverse is true and accurate. I confirm that by accepting a an appointment and / or treatment there is likely a to a related fee.

I indemnify RCMP Dental Group Pty. Ltd. from and against all costs and disbursement incurred in recovering overdue invoices (including but not limited to legal costs, collection agency costs, internal administration costs and bank dishonor fees). I understand that interest on overdue invoices shall accrue daily from the date of unpaid treatment to the date of payment at a rate of four per cent (4.0%) per calendar month.

Name of Patient or Guardian *

First

Last

Date *//

Signature *

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