If you are a new patient, you can save time by printing and completing our Medical History Form and bringing it with you to your appointment.
Date of Birth
Place of Employment
Name of person/s responsible for paying your accounts:
Do you have Private Health Insurance? If Yes, which fund?
Have you had any of the following: (Please check the options that apply)
Do you have any other medical conditions?
Are you pregnant? If so, when is your expected due date?
Have you had a reaction to Local Anaesthetics?
Do you have any Drug Allergies?
Are you currently receiving medical treatment? If so, please give details:
Are you currently taking any medications?
When was your last visit to the Dentist?
Do you require antibiotic prophylactic cover?
What is the reason you have made this appointment?
How did you hear about Perth City Dental Surgery? ---Google (or other search engine)Yellow PagesPCDS WebsiteHBF WebsiteBUPA WebsiteHealth Fund RecommendationSign or other advertisingWord of MouthExisting PatientFamily/FriendWork in BuildingCorporate Dental SchemeReferral from specialistOther
I understand failure to complete Medical Information may place myself and others at medical risk
I give my consent to receive Dental Treatment by my nominated Health Care Provider
In accordance with the Privacy Act 2001, the only time we reveal any of your personal details is when we have to refer you to a Specialist (Dental/Medical), Debt Collection Agency, for General Anaesthetics (Hospital and Anaesthetist/s).
We always aim to create a dental practice that is of greatest convenience to our patients. Being in the city, we understand that many of our patients are office workers and time is of the essence.