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 & Health Fund

Do you have private health cover? *

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? *

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

Have you ever been a smoker? *

YesNo

Year Started Smoking

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 and Our Privacy Policy

In accordance with the Victorian Health Records Act 2001 and Privacy Act:

Our practice respects your right to privacy. We realise that it is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our practice and to whom this information might be disclosed. The policy of our practice is to follow these procedures:

The information collected will be used for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of addressing accounts to you, as well as processing payments and writing to you about our services and any issues affecting your treatment.
We may disclose your health information to other health care professional, or require it from them if, in our judgement, that is necessary in the context of your treatment. In that event, disclosure of your personal details will be minimized wherever possible.
We may also use parts of your health information for research purposes, in study groups or at seminars as this may provide benefit to other patients. Should that happen, your personal identity will not be disclosed without your consent to do so.
Your medical history, treatment records, x-rays and any other material relevant to your treatment will be kept here. You may inspect or request copies of our records of your treatment at any time, or seek an explanation from the dentist. Statutory fees will apply in relation to the types of access you seek. If you request an explanation of our records or a written summary, our usual fees apply to these services.
If any of the information we have about you is inaccurate, you may ask us to alter our records accordingly.

You can otherwise rest assured that your health information will be treated with the utmost confidentiality. Disclosure will not be made to any person not involved in either your treatment or the administration of this practice, without your prior written consent. If you have any queries or concerns about our handling of your health information, please do not hesitate to raise these concerns with our practice.

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 *

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