New Patient Registration & Medical History Form

Patient details

Title
DrMrMrsMsMxMasterMissOther

Gender
MaleFemaleOther

Address

Postcode

Email

If patient is under 18 years old

Parent/Guardian 1

Parent/Guardian 2

If not the patient, the person filling in this form is

This person’s relationship to patient

Telephone number

In an emergency, the person to contact is

This person’s relationship to patient

Telephone number

The person responsible for the account is

What are the reasons for the patient’s visit?

How did you hear about our practice?

Which of our practitioners do you prefer to see?

Patient medical history

Do you have any medical condition?
YesNo

Are you currently taking any medication?
YesNo

Are you allergic to anything?
YesNo

Any previous hospitalisation or operation?
YesNo

Any history of blood-borne infectious disease?
YesNo

Any other significant medical history?
YesNo

Are you currently under a doctor’s care?
YesNo

Your doctor’s name and telephone

Consent for Treatment and Cancellation Policy

Upon diagnosis, I authorise the dental practitioner to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made.I have completed this form to the best of my knowledge and acknowledge that this represents an accurate medical history. On future visits, I will advise the dental practitioner of any changes to the above form.I acknowledge practice policy to give 48 hour business days notice when re-scheduling an appointment, or a fee may apply.I consent for The Myofunctional Centre to use images and treatment history for publications, presentations, or education. I understand that I can refuse consent for such use if I so wish.

Signature