Confidential Medical History Form Page 2
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2How did you hear about Noosa Dental?
Website/Internet ☐
Flyer ☐
Newspaper ☐
Yellow Pages ☐
Personal Referral (please list)
_____________________________
Local Directory ☐
Other (please list)
_____________________________
How long since your last dental visit? _________________________________________________________
How often do you have dental examinations? ___________________________________________________
Yes ☐
No ☐
Have you had any problems with previous dental treatment?
If yes, what was your previous experience?_____________________________________________________
Less than 1 year ☐
Longer than 1 Year ☐
When were your last dental x-rays?
Yes ☐
No ☐
Are you happy with the appearance of your teeth?
If not what would you like changed? __________________________________________________________
Have you had/ noticed any of the following: (please tick)
Does your jaw click or hurt?
Do you smoke?
Do you grind your teeth?
Does floss ever tear between your teeth?
Do you wear a dental guard?
Do your gums bleed when you brush/floss?
Do you bite your lips or cheeks often?
Do you think you have bad breath sometimes?
Have you ever had your bite adjusted?
Do you experience sensitivity to hot/cold?
Have you seen a periodontist?
Do your teeth ever hurt when you bite hard?
Have you had orthodontic treatment?
Do you have spaces/gaps that bother you?
CONSENT FOR TREATMENT (Please read carefully)
I hereby authorise the dentist or designated staff to take x-rays, study models, photographs and other
diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Under the Dental Act, all
records are to be kept seven years by the practice.
Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon
by me and to employ such assistance as required to provide proper care.
I agree to the use of anaesthetics, sedatives and other medication necessary, I fully understand that using
anaesthetic agents embodies certain risks. I understand I can ask for a complete recital of any possible
complications.
I agree to be responsible for payment of all services rendered on my behalf and on behalf of my
dependants/s. I understand that payment is due at time of service unless other arrangements have been
made.
I understand that it is normal practice to send referral letters to other dental specialists & GP's. We
sometimes send copies to other doctors or dental laboratories if we know they are involved in your care.
As your time is valuable you can expect us to be on time with appointments with the exception of
emergency situations. We would appreciate the same courtesy. Rescheduling your appointment requires
48 hours’ notice so the appointment time may be given to another patient otherwise a $100.00 fee applies.
I have read and understood the information regarding how my medical data is obtained and stored. I have
had the opportunity to discuss this with staff at Noosa Dental and agree to the above conditions.
Signature: Name:_________________ Date: ____/____/____
NB: Patients under the age of 18 years must have this form signed by a Parent or Guardian
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