Medical History

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Please fill out the medical history

Title

Full Name

DOB

Address

Postcode

Telephone Home

Telephone Work

Telephone Mobile

Fax No

Name of person responsible for account

Emergency Contact

Emergency Phone

Medical Doctor

Doctor Phone

How would you like to be contacted:

Home Work Mobile Fax Email

Please tick if you have ever had any of the following:

Any prosthetic implant ie: Heart valve, Hip/Knee replacement, Pacemaker History of Rheumatic fever Diabetes Blood pressure: High Blood pressure: Low Heart Ailment Asthma/Chest or breathing problems Smoking

How many per day?

Hepatitis

Type

HIV Epilepsy Tuberculosis Mental Health: Anxiety / Depression Any blood disorders Taking any blood thinner or anticoagulant Kidney or liver disease Low bone density (Osteoporosis) and any injection for treatment?

Please list all medications and or treatments that you are currently taking or receiving.

Do you have any other medical conditions?

Do you have any allergies ? If yes which ones?

Are you pregnant?

Yes No Unsure

Please note that our policy is to receive payment on the day of your treatment.

Date

Thank you for providing this important confidential information Parkridge dental

Parkridge Dental is a conveniently located dental practice with a reputation for up-to-date preventative and cosmetic dental treatments.

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Contact Details

189 Dandelion Drive Rowville VIC 3178 AU
parkridge@rowvilledentists.com.au
Tel: 9752 8800
Emergency No: 0455861932
WhatsApp No: 0455861932

Work Hours

Monday – Friday 9:00 am-6:00 pm

Saturday 9 am–1 pm

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