Salutation (required) ---MrMrsMsDrMasterMiss
Surname (required)
First Name (required)
Address (required)
Suburb (required)
Postcode (required)
Email Address (required)
Date of Birth (required)
Home
Mobile
Work
Medicare Number
Medicare Ref
Nearest Emergency Contact
Emergency Contact Number
How would you like to receive your Dental Recall? (required) ---SMSEmailLetter
Person responsible for account (if other than self)
Private Health Fund
Private Health - Dental Extras? ---YesNo
Private Health Fund Member Number
Private Health Fund Member Ref Number
Have you had or do you have any of the following medical conditions? Select Yes or No
Heart Murmurs (required) ---YesNo
Heart Attack (required) ---YesNo
Asthma (required) ---YesNo
Rheumatic Fever (required) ---YesNo
Epilepsy/Fits (required) ---YesNo
Females Only: Are you pregnant at this time? ---YesNo
Does this patient have special needs? (required) ---YesNo
Blood Pressure: Low / High (required) ---LowHigh
Cardiac Surgery of Pacemaker (required) ---YesNo
Diabetes (required) ---YesNo
Hepatitis (required) ---YesNo
If Yes, hepatitis type ---YesNo
If Yes, hepatitis year ---YesNo
Transmissible Disease (TB/HIV) (required) ---YesNo
Are you allergic to:
Penicillin (required) ---YesNo
Latex (required) ---YesNo
Others ---YesNo
Are you taking Anticoagulant (blood thinning) medication? (required) ---YesNo
Has your medical practitioner specified you require Antibiotic Cover for dental treatment? (required) ---YesNo
Have you had lap band surgery? Yes No Is your weight over 120kg? (required) ---YesNo
Are you currently or have you had treatment for Osteoporosis? (required) ---YesNo
Do you Smoke? (required) ---YesNo
Are you taking any Drugs or Medication at present? (required) ---YesNo
If Yes, please list
Are you currently having or have you had treatment for Cancer OR Bisphosphonates? (required) ---YesNo
If Yes, please select one ---CancerBisphosphonates
Have you previously had ANY reaction to Dental Procedures? (required)
Name of your General Practitioner and Surgery (required)
Are you Aboriginal or Torres Strait Islander? (required) ---YesNo
How did you hear about Moonah Dental Centre? Yellow Pages onlineGoogleFacebookFriends/FamilyYellow Pages BookShopper DocketBus AdvertisementBillboard SignDental ReferralHealth FundOther (please specify below)
If Other, please specify
By clicking below I declare that the information provided is true and correct (required) My information is true and correct
PRIVACY ACKNOWLEDGEMENT 1. We acknowledge our obligation to you under the privacy act 1988 (as amended December 2014) 2. Personal information collected from you will be used primarily to insure that you receive optimal care, but may be used for other purposes. 3. The use of your personal for a limited number of purposes, e g to provide care to you, does not require your consent, if we want to use the information for other purposes we will ask you for your consent. 4. In the event of default, the Customer will be liable for the collection costs incurred.