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

Title *

First name *

Last name *

Date of birth *

Preferred name *

Gender *

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

Full name of person responsible for account *

Contact number of person responsible for account *

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

How did you find out about us? *

If you selected "Other", please let us know how you found us above.

Which patient referred you to us?

Dental Background & Reason For Visit

What is the main reason you’re seeking dental care with us? *

When was your last visit to the dentist? *

How often do you have dental examinations? *

When was your last professional dental cleaning? *

When did you last have full mouth dental x-rays taken? *

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

Current Dental Symptoms & Oral Health

Do you currently experience any of the following? *Please select all that apply.

If you selected ‘Other’, please provide details *

Previous Dental Treatment & Family History

Have you ever had any of the following dental treatments or experiences? *Please select all that apply.

Have your parents experienced gum disease or tooth loss? *

YesNoUnsure

Jaw Function, TMJ & Related Symptoms

Have you ever experienced any of the following jaw, head, neck & muscle symptoms? *

Clicking, popping or other noises in your jawPain or discomfort in your jawDifficulty or discomfort when chewingJaw locking (jaw temporarily getting stuck open or closed)Limited mouth opening / Difficulty opening or closing your mouth fullyClenching or grinding your teethHeadachesNeck or shoulder pain, tightness or muscle sorenessNone of the above

Please select all that apply.

Where do you experience these symptoms? *

Left sideRight sideBoth sidesUnsure

Oral Hygiene & Dental Habits

How often do you brush your teeth? *

How often do you floss between your teeth? *

Which of the following aids or products do you use? *Please select all that apply.

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 Goals, Experiences & Anxiety

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

Medical History

*** It is imperative that you answer all medical questions carefully and provide any further relevant details of your selections ***

Anxiety / Depression / Psychiatric illness *

YesNo

Arthritis / Osteoporosis / Joint Replacement *

YesNo

Asthma / Bronchitis / Sinusitis / Lung disease *

YesNo

Blood clots / DVT / PE *

YesNo

Blood disease / Bleeding disorder *

YesNo

Cancer *

YesNo

Treatment received? *

ChemotherapyRadiotherapyOther

Diabetes *

YesNo

Epilepsy / Seizures *

YesNo

Fainting / Dizzy spells *

YesNo

Heart disease / Arrhythmia *

YesNo

Heart murmur / Congenital heart disease *

YesNo

Heart surgery / Valve replacement *

YesNo

Hepatitis A, B or C / Carrier of Hepatitis *

YesNo

High blood pressure *

YesNo

History of blood transfusions *

YesNo

History of intravenous drug use *

YesNo

HIV / AIDS *

YesNo

Kidney disease *

YesNo

Liver disease *

YesNo

Pacemaker *

YesNo

Reflux / Stomach ulcers *

YesNo

Rheumatic fever *

YesNo

Stroke / Mini stroke *

YesNo

Sleep apnea *

YesNo

Thyroid disorder *

YesNo

Do you have any other medical conditions or health concerns not mentioned above? *

YesNo

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

YesNo

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

YesNo

Are you aware whether you snore? *

YesNo

Medications & Allergies

Are you currently taking any medications, including prescription medications, over-the-counter medicines, herbal remedies or supplements? *

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? *

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

YesNo

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

Smoking & Alcohol Consumption

Do you smoke cigarettes? *

YesNo

Year you started smoking *

Number of cigarettes you smoke per day *

If you no longer smoke, how many years did you smoke for?

Do you drink alcohol? *

YesNo

How often do you drink alcohol? *

How many standard drinks containing alcohol do you have on a typical day when drinking? *

Dento-Facial Aesthetics & Injectables

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

YesNo

What would you wish to improve? *

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

Practice Policies & Payment Information

Payment Policy

Payment is required on the day of treatment.

We accept cash, EFTPOS, Mastercard and Visa. Afterpay and other third-party payment options may also be available. Please speak with our reception team for further information.

Cosmetic & Laser Dentistry Centre is not a preferred provider for any health fund. Patients with private health insurance may still be eligible to claim rebates for eligible dental treatments, depending on their level of cover and individual health fund policy.

If your overdue account is referred to a collection agency and/or law firm, you may be liable for the costs incurred in recovering the debt, including legal demand costs, to the extent permitted by law.

Cancellation & Rescheduling Policy

Appointments are reserved exclusively for each patient. If you need to cancel or reschedule your appointment, please provide at least 48 hours' notice to avoid a cancellation or rescheduling fee.

Appointments cancelled or rescheduled with less than 48 hours' notice may incur a fee.

Your Health Information & Privacy

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 & Signature

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

Are you completing this form on behalf of a patient as their parent or legal guardian? *

YesNo

Full name of parent or legal guardian completing this form *

Patient signature *

Clear

Signature of parent or legal guardian *

Clear

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