Medical History Form - Norlane Dental Aesthetics and Implants

Day	Hours
M	08:30 AM – 06:30 PM
T	08:30 AM – 06:30 PM
W	08:30 AM – 06:30 PM
T	08:30 AM – 06:30 PM
F	08:30 AM – 05:30 PM
S	08:30 AM – 04:00 PM
S	Closed

What is the main purpose of your visit today?

General Implants Orthodontics Emergency

First Name:

Last Name:

Email:

Date of Birth:

Member Number:

Health Fund:

Emergency Contact Name:

Emergency Contact Number:

To complete only if the patient is under 18 years old

Guardian Name:

Guardian Phone Details:

Guardian Contact Address:

Name of your GP:

Doctor’s Phone No:

Your Doctor’s address:

Are you pregnant? If yes, how many months?

Have you had any serious illnesses in the last 2 years?

Yes No

Are you currently taking any medications or tablets regularly?

Yes No

Do you have any allergies to Penicillin or other drugs?

Yes No

Is your blood pressure normal, high or low?

Normal High Low

Do you suffer from sleep apnoea?

Yes No

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

How long since your last dental visit?

Does dental treatment make you nervous?

No Slightly Moderately Extremely

Have you ever had or require the following for dental treatment?

Gas (Nitrous oxide-laughing gas) Intravenous sedation General Anaesthesia

• I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics as indicated and I will assume responsibility for the fees associated with those procedures.

• I understand that the practice requires at least 48 hours notice if I need to cancel my scheduled appointment and hat a cancellation fee may apply.

• I am aware that payment is required on the day of treatment.

• We provide as a courtesy to our patients a preventative recall program that offers a recall reminder if you have not been to the practice in 6 months.

Do you wish to receive a recall reminder?

Yes No