Please take a few moments to answer the following questions to help us provide the best dental treatment for you.  Please print or circle.

Mr/Mrs/Miss/Ms Full  Name:………………………………………………………………………….…………….DOB:…………………..………

Postal address:…………………………………………………………………………………………..……………………………..………………………..

Phone: Home:………………………………...…Work:………………………………...…Mobile:………..……………………….………………….

Would you like SMS reminders sent to your mobile?   YES  /  NO

Employer:……………………………………………Address:………………………………………………………………………………………………..

Do you have Private Dental Insurance with a Health Fund?     NO / YES – Fund Name:………………………….

Are you covered by Veterans Affairs?      YES  /  NO                

When did you last visit a Dentist?............................................................

What is the purpose of your visit today?.......................................................................................................

Have you been in Hospital during the last twelve months?      YES  /  NO

What Drugs / Medications / Supplements including dosage are you currently taking or have taken within last six months.

If YES Details:………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………..

How do you rate you general health?    GOOD       FAIR          POOR                       Are you pregnant?    YES  /  NO

Your Doctors name:……………………………………………………………Address:……………………………………………………………………

Have you ever suffered from any of the following?

Heart Disease………………..……………...YES/NO                                   Allergic to Penicillin ……………...... YES/NO

Rheumatic fever…..……………..….…….YES/NO                                   Asthma………………..…………………..….......YES/NO

Blood Disease/ Bleeder…….…..……...YES/NO                                   Allergy/Hypersensitivity…….…….………..YES/NO

Stroke…………………………………..……….YES/NO                                  Osteoporosis…………………………….…..…..YES/NO         

Diabetes…………………………………….….YES/NO                                  Blood pressure problems………….………..YES/NO

Are you a smoker?...........................YES/NO                                   Hepatitis B, C,  HIV………………………….....YES/NO                 

 Any other dental problems/issues?......................................................................................................................

Your information is kept in accordance with The Health Records and Information Privacy Act 2002 (NSW).

Watkins Dental wishes to advise a copy of the Australian Charter of Healthcare Rights is available on request.

 

*Please sign if you Consent for us to collect and store your medical, dental, and personal history.

 

Patient signature:………………………………………………………………..………………………………Date: ………………….…………

Carer/ Guardian

WELCOME TO WATKINS DENTAL

Make an Appointment
Find us

89 Byng St

Orange NSW 2800

Tel: 02 6362 8612