Welcome to Cosmetic & Laser Dentistry Centre

So that we can provide you with the best possible care, please complete our comprehensive dental & medical history questionnaire. Please note that all information is confidential and stored securely.

Note: If you are having difficulties with our online form, you can always complete our paper-based form when you attend your appointment. However, please allow 15 minutes ahead of your appointment time to do so.

Personal Details

First name *

Last name *

Preferred name *

Gender *

MaleFemaleOther

Employer

Occupation

Contact Details

Phone number *

Email address *

Residential Address *

Street address *

Suburb *

State *

Postcode *

Are you on Instagram? *

YesNo

Billing, Medicare & Private Health Insurance

Do you have Medicare? *

YesNo

Medicare number *

Reference number *

Card expiration date *

Do you have private health insurance? *

YesNo

Health fund name *

Will you be the person responsible for your account? *

YesNo

Person responsible for account (if "NO" selected above)

Contact number of person responsible

Their Address

Street address

Suburb

State

Postcode

Next of Kin / Emergency Contact

In case of an emergency, who should we contact? *

Emergency contact phone number *

Relationship to you *

Emergency contact address

Street address

Suburb

State

Postcode

Referral Information

Dental Health Questions

What is the main reason for your first visit to our practice? *

Previous dentist's details: *If not applicable, please give reason instead. e.g. I have not visited a dentist before.

Your Dental Habits

How often do you brush your teeth? *

Twice or more dailyAt least once a dayLess than every dayDon't brush (or can't brush)

Do you bite your lips or cheeks regularly? *

YesNo

Do you chew, hold or bite on foreign objects with your teeth? *

YesNo

Breathe through your mouth while awake or asleep? *

YesNo

Dental Health & Treatment History

Do you ever experience tooth sensitivity? * *

YesNo

Are your teeth sensitive to *

ColdHotSweets or sugarBiting or chewing

Have you noticed any mouth odours or bad tastes? *

YesNo

Do you frequently get sores, blisters or other oral lesions? *

YesNo

Do your gums ever bleed or hurt? *

YesNo

Have your parents experienced gum disease or tooth loss? *

YesNoUnsurePrefer to not answer

Have you noticed any loose teeth or a change in your bite? *

YesNo

Please tick any of the following you have had in the past: *

Do you experience any of these jaw symptoms?

Clicking Jaw? *

YesNoSometimes

Jaw locking open? *

YesNoSometimes

Grating or grinding jaw noises? *

YesNoSometimes

Limited mouth opening? *

YesNoSometimes

Clench or grind teeth whilst awake or asleep? *

YesNoSometimes

Have you ever experienced:

Difficulty chewing on either side or the mouth? *

YesNo

Headaches, neck or shoulder ache? *

YesNo

Sore muscles in the neck or shoulders? *

YesNo

Your Dental Experiences

Are you entirely satisfied with the appearance of your teeth? *

YesNo

What would you ideally wish to improve?

Would you like to keep all of your teeth for the duration of your life? *

YesNo

Do you feel nervous about having dental treatment? *

YesNo

What is your biggest concern?

Have you ever had an upsetting dental experience? *

YesNo

Would you like to share the details with us?

Medical Health Questions

Have you been under the care of a doctor or physician in the past 2 years? *

YesNo

Practitioner's Details *

Have you been admitted to hospital over the past 5 years? *

YesNo

Reason for Admission? *

Have you lost or gained more than 4.5 kilograms in the past year? *

YesNo

Have you been vaccinated against COVID-19? *

Yes - Fully VaccinatedYes - Partially VaccinatedNo

Medical Conditions - Current and Previous

It is important that you answer all medical questions carefully.

Have you experienced any of the following conditions?

Heart disease / Arrhythmia *

YesNo

Heart murmur / congenital heart disease *

YesNo

Heart surgery / valve replacement *

YesNo

Rheumatic fever *

YesNo

Pacemaker *

YesNo

Stroke / mini stroke *

YesNo

Blood clots / DVT / PE *

YesNo

High blood pressure *

YesNo

Blood disease / bleeding disorder *

YesNo

Arthritis / Osteoporosis / Joint Replacement *

YesNo

Hepatitis A, B or C / Carrier of Hepatitis *

YesNo

HIV / AIDS *

YesNo

Thyroid disorder *

YesNo

Asthma / Bronchitis / Sinusitis / Lung disease *

YesNo

Sleep apnea *

YesNo

Liver disease *

YesNo

Kidney disease *

YesNo

Epilepsy / seizures *

YesNo

Fainting / dizzy spells *

YesNo

Reflux / stomach ulcers *

YesNo

Diabetes *

YesNo

Cancer *

YesNo

Radiotherapy / Chemotherapy *

YesNo

History of blood transfusions *

YesNo

Use of intravenous drugs *

YesNo

Anxiety / Depression / Psychiatric illness *

YesNo

If you answered "Yes" to any of the above, please specify details:e.g: Year of diagnosis, status and any previous or ongoing treatment or procedures

Do you wake up in the morning still feeling tired? *

YesNo

Are you aware whether you snore? *

YesNo

Have you experienced any other medical conditions not specified above? *

YesNo

Please provide further details as appropriate:

Smoking History

Do you smoke cigarettes? *

YesNo

Year you started smoking

If you no longer smoke, when did you quit?

Number of cigarettes you smoke per day

Alcohol Intake

How frequently do you drink alcohol? *

Allergies

Do you have any allergies to medications, materials or foods? *

YesNo

IMPORTANT: Please specify allergy details *e.g. Local anaesthetic, latex, penicillin, peanuts

Medications

Are you currently taking any medications or herbal medicines? *

YesNo

Please list all medications and dosage:Please provide a detailed list of ALL prescription and non-prescription medications you are currently taking and the doses e.g. Aspirin 100mg 1 tablet once a day, Endep 25mg 1 tablet once a day, etc including herbal medicines such as St John’s Wort, Ginko Biloba, etc.

Are you taking, or have you ever taken, bisphosphonates (Eg: Fosamax, Aredia, Aclasta, Actonel, Didronel, Reclast, Pamisol, Skelid, Zometa): *

YesNo

When did you stop taking them? *

How many years did you take them? *

Other health concerns

Are there any other conditions which may impact your health? *

YesNo

Please list or describe any other conditions which may impact your health.

Would you like to discuss any of the above in private with the clinician? *

YesNo

Dento-Facial Aesthetics

Are you happy with the overall appearance of your face? *

YesNo

Is there anything you would wish to improve?

Aesthetic Injectables

Have you ever undergone treatment using any of the following?

Botulinum toxin (Botox, Dysport) *

YesNo

Dermal fillers (Restalyne, Juvederm, Hyaluronic acid) *

YesNo

Other facial cosmetic injections *

YesNo

Accounts Terms

Please note that our policy is to receive payment on the day of your treatment.

We accept Cash, EFTPOS, MasterCard and Visa.

In the event where your overdue account is referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs.

Cancelling/Rescheduling Appointment Terms

Please note that once you have booked an appointment with us it means that we have reserved time in our schedule exclusively for you. If you cancel or reschedule your appointment less than 48 hours before it is scheduled to take place you will be subject to a fee. To avoid this fee, we kindly ask that you please provide notice at least 48 hours prior to your appointment.

Notice For Patient Information

Your Health Information, Privacy & Practice Policies

In accordance with the Victorian Health Records Act 2001 and Privacy Act, our practice is committed to protecting your personal information and ensuring transparency about how it is collected, stored, and used.

Privacy and Confidentiality

Our practice respects your right to privacy. It is important to us that you understand the purpose for which we collect your health details and how this information is handled:

Your personal and medical information is collected for the primary purpose of providing quality dental care.
Personal details such as your name, address, and insurance information may be used for administrative purposes such as billing, correspondence, and appointment management.
We may share your health information with other healthcare professionals involved in your care, but only when necessary and with minimal disclosure of personal details.
Occasionally, anonymised data may be used for research, seminars, or study groups to improve patient care. Your identity will never be revealed without your explicit consent.
You are entitled to access your health records and may request corrections if any information is inaccurate. Statutory fees may apply for access or summaries.
Your records, including treatment notes and x-rays, are securely stored and treated with strict confidentiality.
No disclosure will be made to individuals outside your care team or our administrative staff without your written consent.

If you have any concerns about how your information is handled, please raise them with our team—we are always here to help.

Practice Policy: Recording of Consultations

To maintain a respectful, comfortable, and legally compliant environment, we kindly ask that no audio or video recordings of consultations, treatments, or discussions be made without prior consent from all parties involved.

We understand that some patients may wish to record parts of their consultation to help remember important information. If this is the case, please let us know—such requests will be respectfully considered when all participants are comfortable.

This policy is designed to:

Protect the privacy and dignity of all individuals.
Ensure informed consent and accurate communication.
Maintain a safe and trusting environment for your care.

We appreciate your understanding and cooperation. If you have any questions about this policy, please don't hesitate to speak with a member of our team.

Acknowledgement and Signature

I acknowledge that I have read, understood and accept all terms and conditions in this medical history form.
*

Have you completed this form for another person in capacity as parent or guardian? *

No - this form pertains to me personallyYes - this form is for my dependant

Patient's Full Name (Dependant) *

PARENT OR GUARDIAN SIGNATORY FULL NAME: *

Patient Signature *

Draw signature|Type signatureClear