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.

 

GENERAL INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

DECLARATION

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!