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(07) 3114 1199
0406 579 197
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(07) 3114 1199
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Skygate Dental Medical History Form
Please enable JavaScript in your browser to complete this form.
Personal & Emergency Contact Information
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Mr.
Mrs.
Miss.
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Prof.
Master.
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Address
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Address Line 1
City
State / Province / Region
Postal Code
Contact Number
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Email:
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Email
Confirm Email
Occupation:
Emergency Contact Information
Emergency Contact Name:
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First
Last
Emergency Contact Relationship:
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Father
Mother
Son
Daughter
Sister
Brother
Partner
Friend
Wife
Husband
Other
Emergency Contact Number:
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Next
Health Fund Information
Do you have a Private Healthfund?
*
Yes
No
Please Select Your Fund
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ACA
AHM Health Insurance
Australian Unity Health
Bupa
CBHS Health Fund
CUA Health
Defence Health Limited
Doctors Health Fund
FRANK
GMHBA Limited
Grand United (GU)
HBF
Hospital Contribution Fund (HCF)
Health Care Insurance
Health Insurance Fund of Australia (HIF)
Health Partners
Health.com.au
Medibank Private
Mildura Health
National Health Benefits Australia (One Medifund)
Navy Health
NIB
Nurses & Midwives Health
Peoplecare
Phoenix Health
Police Health
Queensland Country Health
Railway and Transport Health
Reserve Bank Health Society
Teachers Health Fund
Transport Health
TUH
Westfund
Qantas
Other
Health Fund Name
*
Member Number
*
Series Number (Number Next to your Name)
*
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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
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Number Next to Patients Name:
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Full Name of Patient (As Per Medicare Card)
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Medical Information
Any Majory Surgeries / Operations or Illnesses in the last 2 years?
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Yes
No
Surgery / Illness Information
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Date of Surgery
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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)
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Do you have any Abnormal Reactions to Local or General Anaesthesia?
*
Yes
No
Additional Information
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Do you Smoke?
*
Yes
No
How Many Per Day (Approximately)
Selected Value:
0
Are you Pregnant?
*
Yes
No
Unsure
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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
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Date of Last Follow up:
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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):
*
General Practitioner (GP) Clinic
*
General Practitioner (GP) Name
*
General Practitoner (GP) Address
Address Line 1
City
State / Province / Region
Postal Code
Phone
*
Previous
Next
Please describe the dental problem(s) you are experiencing:
*
Please provide any additional information
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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 three per cent (4.0%) per calendar month.
Name of Patient or Guardian
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First
Last
Date
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