So we can ensure we are looking after your needs, please review and complete the following questionnaire

Title*:

Surname*: First Name(s)*:

Preferred Name: Date of Birth*:

Address:

Suburb: Postcode:

Mobile*: Work:

Email*:

Occupation:

Person Responsible for fee (if not yourself):

Do you have Private Health Insurance?
If Yes, which company:

How did you find out about our practice? Person Referral, name:

Have you visited our website? Do you “like” us on Facebook?

Have you had any of the follow?

Heart problems  YES
Blood pressure  YES
Artificial joints  YES
Rheumatic fever  YES
Circulatory problems  YES
Radiation treatment  YES
Excessive bleeding  YES
Excessive bruising  YES
Ulcers (stomach)  YES
Sinus trouble  YES
Tumor history  YES
Allergies to anaesthetics  YES
Allergies to penicillin  YES
Allergies to medication  YES
Allergies to latex  YES
Anemia or other blood disorders  YES
Diabetes  YES
Asthma  YES
Hepatitis A B C D E  YES
Epilepsy  YES
Liver or kidney problems  YES

Are you currently taking any medications?

If ‘yes’, please list:

Please list any other allergies:

Have you had any of the following?

Does your jaw click or hurt?  YES
Do you feel you grind your teeth?  YES
Have you ever had orthodontic treatment?  YES
Do you wear a night guard?  YES
Have you ever had gum disease?  YES
Have you ever had your bite adjusted?  YES
Do you bite your lips or cheek often?  YES
Do you smoke?  YES
Do you think you have occasional bad breath?  YES
Do your gums ever bleed when you brush your teeth?  YES
Do you experience sensitivity with hot/cold?  YES
Does floss ever tear between your teeth?  YES
Does food get jammed between your teeth?  YES
Do your teeth ever hurt when you bite hard?  YES

Other notes:

Name of your general doctor:

Address: Phone:

Are you pregnant?  YES If yes, what is your due date?

How long since your last dental appointment?

How often do you have dental examinations?

Previous dental x-rays were taken:  Less than a year ago Longer than a year ago

Consent for Treatment

1. I hereby authorise the dentist or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by dentist to make a thorough diagnosis.
2. 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.
3. I agree to the use of anaesthetics, sedatives and other medications as necessary. I fully understand that using anaesthetic agents embodies certain risks.
4. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependants. I understand that payment is due at the time of service.
5. I agree in the event that I need to reschedule my appointment 48hours notice must be given to the practice or a cancellation fee is payable by myself.
6. I authorise any photographs (before, during or after) of treatment performed may be used at the discretion of SmileBright Dental as examples, with my privacy being intact at all times.

Patients Signature*: Date*:

Parent/Responsible Party Signature: Date: