OHB Medical for Adults - DentalCareXtra

New Patient or updated Patient Details

Patient First Name(Required)

Patient Last Name(Required)

DOB(Required)

Practice Location(Required)

Which location is managing your booking?

Gender(Required)

Mobile Phone or best contact number(Required)

Email(Required)

Address(Required)

Address Suburb Post code

Do you have private health insurance for dental?(Required)

Yes

**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.

If yes - we need your Health Insurance Details please

Please enter which fund, membership number and the reference next to your name. E.g. Westfund - 1234567 - Ref 1

Emergency Contact Person (first and last name)(Required)

Relationship to you(Required)

Mobile Number(Required)

Who can we thank for referring you to us?(Required)

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.

Name of GP / Medical Centre attended(Required)

Health History(Required)

Please check any boxes that apply

Any other medical condition not listed we should know about?

Are you under any medical care at present?

If yes, please provide Specialist's name, Profession & name of practice

Are you a smoker?(Required)

Yes often

Occasionally/Socially

Any medications or supplements taken ? E.g., are you taking any prescription medications or supplements such as fish oil?(Required)

Yes

If Yes - please advise what medication/supplement taken?

e.g. Some natural supplements can have an affect on blood clotting.

Allergies?(Required)

Penicillin

Latex

Dairy

Dust/ & or Pollen

Bactrim

Nuts

Other medications

No known allergies

Please advise of any allergies not listed

Have you had any surgery in last 5 years?(Required)

Yes

If yes, please briefly advise what type of surgery and when

Immunisations - Are they up to date?(Required)

Yes

Dental History

When did you last visit the dentist?(Required)

Return visit to Oral Health & Beyond

Less than 1 year

More than 1 year

More than 2 years

Long time ago - don't remember

If you have been seen at another dentist, we can arrange to have their records transferred over. Please advise who and when approximately

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)

Yes

Other

How well do you tolerate dental/medical care?(Required)

well

poorly

unsure

How many times a day are you brushing your teeth?(Required)

zero

Have you ever had any dental x-rays taken?

Yes

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?

Yes

Acknowledgement

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)

Yes I consent

Please ask my consent prior to any photos being taken

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)

Yes

Only reminders about my appointments preferred

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)

First Last

Date(Required)

29011