Patient Personal & Medical Questionnaire

Private & Confidential - The details you provide to us on this form are encrypted for your privacy.

Please answer these questions as completely as possible. It will greatly assist us to provide the best care for you.

Patient Details:


Contact Details:


Emergency Contact Details:


Please answer the following questions in regards to dental treatment:

The state of your health may have a very significant effect on your dental care. Please answer these questions fully or discuss them with your dentist:

Some medicines may interfere with your dental treatment or react with medicaments used by your dentist.  It is important that your dentist knows precisely what medications (if any) that you are taking.

Please provide details (including dose and frequency) of any medicine or medication that you are currently taking, or have been taking recently.

If you are in any doubt about your medication, please bring the bottle or packet(s) to the practice to show the dentist.

Please indicate YES or NO if you have ever had any of the following:

Declaration:

In signing this form I acknowledge that this represents an accurate medical history.

I will advise my dentist of any changes to my medical history in the future.

I understand that all medical details will be treated with complete professional confidentiality. I have read the privacy document provided by this practice.

I GIVE / DO NOT GIVE Absolute Dental permission to release information to the following third parties:

Sign Here