Patient Information and Medical History Form


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This form is also able to be downloaded here Patient Information Form


Title. Mr / Mst / Mrs / Ms/ Miss/ Dr/ Other________________
Name_____________________________________________________________________________ DOB________________________
Address___________________________________________________________________________Post Code_________________
Home Ph______________________Mobile Ph__________________________Email______________________________________
How did you hear about us?__________________________________________________________________________________

Medical Dr Name and Practice-_______________________________________________________________________________
List any medications you are taking_________________________________________________________________________
Are you allergic to anything?_________________________________________________________________________________
Please tick any of the following conditions you may have:

󠅌 Asthma
󠅌 Chest or lung disease
󠅌 Heart Murmur
󠅌 Rheumatic fever
󠅌 Other heart problems
󠅌 High Blood Pressure
󠅌 Stroke
󠅌 Epilepsy
󠅌 Diabetes
󠅌 Kidney problems
󠅌 Liver problems
󠅌 Hepatitis
󠅌 Gastric problems
󠅌 Bleeding problems
󠅌 Depressive illness
󠅌 Radiotherapy
󠅌 Joint replacement
Date placed__________________


Any other conditions not listed_______________________________________________________________________________
Do you smoke?________________________Any drug or alcohol addictions?_____________________________________
Women- are you pregnant? Y / N If yes what trimester?__________________________________________
Name and contact number of emergency contact___________________________________________________________
Occasionally photos may be taken of your teeth (not your face) – are you happy for these photos to be used on the website? Y / N

By signing this form, you are accepting full financial responsibility for dental treatment (except when covered by the DHB) and that payment is due at the time services are provided. Unpaid accounts will incur additional charges.
Health and safety – Our dental chairs are rated hold to 120kg, we accept no responsibility should injury occur if you are over this rated weight.