Personal Details

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Medical History

Personal Details (All Information will be treated with complete professional confidentiality)
Title: Mr Mrs Ms Miss Mst Dr

Surname: Given Name(s):

Address: Suburb:

Post Code: Date of Birth: Occupation:

Tel: Home Mobile: Work:


How did you hear about our practice? Friend/Relative Website Yellow Pages Walking by

Private Health Insurance: Private Health Fund with Dental Extras? Yes No

Name: Policy Number: Patient ID Number:

Please indicate below if you have had or have at present:

  • Rheumatic Fever

  • Hepatitis A, B, C


  • Stroke

  • Pacemaker

  • Heart Disease

  • Heart Valve Replacement

  • Joint Replacement ( Hip, Knee, Etc)

  • Previous Infective Endocarditis

  • Radiation/Chemotherapy Treatment

  • Diabetes

  • Asthma

  • Epilepsy

  • High / Low Blood Pressure

  • Haemophilia / Bleeding Problem

  • Other:

Do you have any allergies? E.g. Penicillin, Latex?

Females: are you pregnant? Yes No

Do you smoke? Yes No

Are you currently taking any medication? Yes No If Yes, please write medication and dosage;

Are you taking or have taken Bisphosphonate medication? E.g. Fosamax, Actonel?

Family Doctor’s name and address:

  • I declare that the information given above is true and complete. I agree to assume full financial responsibility for all treatment and services rendered.

  • I authorize for St Marys Dental Care to use my intra and extra oral images and photographs for dental education purposes

  • I authorize for St Marys Dental Care to use my intra and extra oral images and photographs on the St Marys Dental website following the AHPRA and ADA guidelines.

Please note that we require 24 hours notice when cancelling an appointment. If less than 24 hours a fee may occur.

Signature: Date:

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