Your Details

It is important for us to know details about your medical history as these could affect the success of your oral health care. The information provided is confidential and will be handled in accordance with our privacy policy.
First Name
Last Name
Date of Birth
Occupation
Address
Email
Phone (Home)
Phone (Mobile)
Phone (Work)
Interests
Private Health Insurance

Your Emergency Contacts

Emergency Contact Name
Phone
Relationship
Doctor's Name
Doctor's Phone

Your Health

How happy are you with your smile? *
1
2
3
4
5
6
7
8
9
10
Are you interested in whitening? *
Yes
No
How long since your last dental visit?
Are you pregnant? *
Yes
No
Due Date
Any known allergies? *
Yes
No
If yes, please list
Any known reactions to anaesthesia? *
Yes
No
If yes, please list
Do you require antibiotic cover BEFORE dental treatment? *
Yes
No
Are you taking medication for bone disease? *
Yes
No
If yes, please list
Current medications
Please indicate if you have, or have you ever had any of the following medical conditions? *
Asthma
High | Low Blood Pressure
Smoker
Diabetes
Cold Sores
Excessive Bleeding
Hepatitis A | B | C
HIV | AIDS
Rheumatic Fever
Bronchitis, Emphysema or Lung Condition
Stroke
Tuberculosis
Heart Murmur
Heart Complaint
Cardiac Pace Maker
Heart Valve Disorder
Thyroid Disease
Kidney Disease
Epilepsy
Radiation Therapy
Stomach or Digestive Condition
Prosthetic Implant
Osteoporosis
Transplant: Organ | Marrow
Anaemia, Leukaemia or other Blood Diseases
Grinding / Clenching
Sleep Aids (e.g. CPAP)
Sleep Study
Snoring
Additional notes or conditions
Referred By
Health Fund
TV Advert
Yellow Pages
Street Sign
Facebook
Google
Or Another Patient (Name)
Do you consent to your treatment discussions being recorded for treatment planning purposes? *
Yes
No

Sign up to the Casey Dentists Newsletter

BUPA Health Insurance
CBHS
HCF
Smile Dental Insurance
TUH Health Fund
National ADF Family Health PRogram
Defence Health