New Patient or updated Patient Details

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Which location is managing your booking?
Do you have private health insurance for dental?(Required)
**Oral Health & Beyond has no affiliation with any health insurance company, however we do have the hicaps system and in most cases you can claim on the spot and pay any gap amount.
e.g. person, health professional, google, social media, radio, billboard etc.

Health History

This information is collected to understand your health history. As some medical conditions can contradict dental treatment, it's important information your dentist needs to know.
Health History(Required)
Please check any boxes that apply
If yes, please provide Specialist's name, Profession & name of practice
Are you a smoker?(Required)
Any medications or supplements taken ?(Required)
e.g. Some natural supplements can have an affect on blood clotting.
Have you had any surgery in last 5 years?(Required)
Immunisations - Are they up to date?(Required)

Dental History

When did you last visit the dentist?(Required)
This will require you signing a Request for records Consent. **Especially if any dental x-rays were previously taken, as Oral Health & Beyond will only take diagnostic images if clinically necessary.
What is the reason for your visit with us?(Required)
Have you ever had an unfavourable dental visit?(Required)

How well do you tolerate dental/medical care?(Required)
How many times a day are you brushing your teeth?(Required)
Have you ever had any dental x-rays taken?
If clinically required, dental x-rays are an important part of diagnosing your dental health. Oral Health & Beyond uses very low dose radiation equipment. This will be discussed if needed, as your consent is required.
Is there a history of dental decay or missing teeth in the family?


I submit this medical form on behalf of my child & I understand that this information is correct to the best of my knowledge. I understand it will be held strictest confidence and only used to improve the quality of the service provided.
Acknowledgement - Photographs(Required)
Photos are routinely taken for dental/myofunctional, research & education purposes and in most cases these are for your dental records & kept on file only. Oral Health & Beyond does sometimes takes fun photos for use on social media, but will always ask your permission. I understand that if photos of me are used, first name may be used but all other identifying information will be kept confidential. I do not expect compensation, financial or otherwise for the use of images.
Acknowledgement - Marketing(Required)
Oral Health & Beyond uses emails for patient contact Promotional, reminders, competitions. You can unsubscribe at any time if you so wish.
Name of responsible party(Required)
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