Patient Medical and Dental History
Welcome to our Practice

Correct answers to the following questions will allow your dentist to treat you on a more individual basis, providing the care appropriate for your particular needs. Your answers are for our records only and will be considered confidential.






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.
Your medical History may be provided to specialists in the case of referral.
I understand that all medical details will be treated with complete professional confidentiality.
I also understand that I am fully responsible for the financial aspect of my dental treatment.

I,     hereby authorize Dr.      to take photographs of my face, jaws, mouth, and teeth.

I understand that the photographs will be used as a record of my care, and may be used for educational purposes in the practice. I further understand that if the photographs are used in any publication or as a part of a demonstration, my name or other identifying information will be kept confidential.

I do not expect compensation, financial or otherwise, for the use of these photographs.

Call us today on 08 9305 1902 and see why Brighton Beach Dental patients are happier!