Patient Information and Medical History

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Title *

Name (first and last name) *

Preferred Name

Date of Birth *

YYYY

Email *

Postal Address *

Phone number *

Occupation

How did you find out about us? *

Do you have a Veterans Affairs card?

Do you have Private Health Insurance (Extras)?

Yes

Clear selection

If yes, which insurer are you with?

Do you have a Medicare card? If so, card number and individual reference (i.e. 1, 2, 3,4, 5).

Are you allergic to any medications or materials (i.e. Latex)? Please list all. *

Do you take any medications? Please list all. *

To the best of your knowledge, do you or have you ever had any of the following (please tick the appropriate boxes). *

Heart Disease

Pacemaker

High Blood Pressure

Low Blood Pressure

Osteoporosis

Kidney Problems

Anxiety/Depression

Radiation therapy

Chemotherapy

HIV/AIDS

Prosthetic Heart Value

Psychiatric treatment

Pheumatic Fever

Stroke

Recent/pending surgery

Epilepsy

Diabetes I

Diabetes II

Hepatitis A

Hepatitis B

Hepatitis C

Lung Problems

Asthma

Endocarditis

Fibromyalgia

Required

Do you have any medical issues not outlined above?

Are you currently pregnant? *

Yes

Terms of Entry *

Welcome to Seaford Dental.The following terms are very important for a safe dental visit at this site. By entering these premises, you declare to have complied with all SA Health directions and not have been in contact with any close or casual contacts of Covid 19. You agree to treat all staff with respect and to follow where appropriate their directions (this may include wearing a mask). You agree that threats of violence towards staff are unacceptable. We value your and our privacy, so to be clear, you agree not to make recordings whether electronic or otherwise of processes or procedures without written consent. Sometimes, we may need to take pictures or make recordings whether electronic or otherwise for quality assurance, treatment and/or teaching purposes and you need to know that these may be shared with those associated with your treatment including dental or medical specialists. This practice will endeavor to provide the best standard of care for you and your family however not all treatment is risk free and sometimes there will be discomfort, swelling, bleeding and sensitivity. You agree that unless previously agreed to that accounts are to be settled at the end of the dental visit. See further terms and conditions on public display (front door) or asks staff for a hard copy. These terms of entry also acts as a non disclosure agreement, meaning you or your responsible party cannot disclosed any communication electronic or otherwise to 3rd parties. Thank you once again for choosing Seaford Dental.

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