New Patient and Medical History Form Home 5 New Patient and Medical History Form Step 1 of 2 50% New Patient FormTitle: Master Mr Ms Mrs Dr Prof Sex: Male Female Other SurnameFirst NameDate of Birth DD slash MM slash YYYY Preferred NameEmail Home PhoneMobileWorkEmergency Contact InformationContact NameRelationshipContact NumberMedicare NumberRefValid ToHealth FundMembership NumberRefPatient Referral Source: Google Walk By Facebook Instagram Official CGD Website Family/Friend Recommendation (Name of Patient) Family/Friend Recommendation (Name of Patient)What is the reason for your visit today?Is there any future procedures you’d like to have done?Are there any concerns you’d like to let Dr Raj know before we begin? Yes No Please specify your concernAre you interested in any of the following: Veneers Whitening NOA OrthoApnea Clear Aligners Medical HistoryHave you ever been hospitalised? Yes No Please provide any relevant information (Have you ever been hospitalised?)Have you had a joint replacement surgery? Yes No Please provide any relevant information (Have you had a joint replacement surgery?)Are you under the care of a Doctor/Carer? Yes No Please provide any relevant information (Are you under the care of a Doctor/Carer?)Are you taking any medications? Yes No What medications are you taking?Any known allergies? Yes No Please specify (Any known allergies?)Do you smoke? Yes No Please provide any relevant information (Do you smoke?)Have you ever suffered from: Asthma Blood Disease High Blood Pressure Low Blood Pressure Diabetes Epilepsy Haemophilia/Prolonged Bleeding Heart Condition Hepatitis HIV/AIDS Rheumatic Fever For Women:Are you pregnant? Yes No On Contraceptive? Yes No Do you require any antibiotics before treatment? Yes No Do you have any other important health issues? Yes No Please specify (Do you have any other important health issues?)Privacy Policy and ConsentAll personal information collected by Carina Gardens Dental is handled in accordance with our Privacy Policy. We will not share your details without your consent. By signing this form you hereby agree and acknowledge that: (i) you have accurately completed the patient/medical history to the best of your knowledge; (ii) you consent to any treatment agreed upon, to be carried out by the dentists and their staff; (iii) you are responsible for payment of all services rendered on your behalf and on behalf of your dependents; (iv) payment is due at the time of service unless other arrangements have been made; and (v) your dentists may take images of your teeth both before and after your treatment. These images may be used in a practice portfolio to showcase examples of dental work to other patients (your identity will remain anonymous).Full Name (consent) First Name Last Name SignatureDate (Consent) DD slash MM slash YYYY
