HOME    SERVICES    ABOUT US    LOCATION    CONTACT    PHOTO GALLERY

HISTORY    DOWNLOADS    INFO    LINKS    PAF    HIPHOP     MISCELLANEOUS

Patient Acquaintance Form Guidelines
  • Before your first appointment you will be asked to fill out this form completely.
  • We are legally required to have the following information in order to render safe treatment of the highest standard.
  • All information given to us by you will be handled confidentially.
  • You can print out the form and fill it out in the comfort of your home or office and bring it to the practice.
  • You can email the form to us.
  • You can fill out the form in the practice. Please arrive early if you wish to fill out the form in the practice.
  • Please inform us of any changes in the future.
Patient Acquaintance Form

  1. Gender.........Mr...Mrs...Miss...Ms...Master.:___________________________________________
  2. Address private:_________________________________________________________________
  3. Address private Street:____________________________________________________________
  4. Address private Suburb:___________________________________________________________
  5. Address private Postcode:_________________________________________________________
  6. Address business:________________________________________________________________
  7. Address business Street:___________________________________________________________
  8. Address business Suburb:__________________________________________________________
  9. Address business Postcode:________________________________________________________
  10. Phone private:___________________________________________________________________
  11. Phone business:__________________________________________________________________
  12. Fax private:_____________________________________________________________________
  13. Fax business:____________________________________________________________________
  14. Mobile private:__________________________________________________________________
  15. Mobile business:_________________________________________________________________
  16. email private:____________________________________________________________________
  17. email business:___________________________________________________________________
  18. skype private:___________________________________________________________________
  19. skype business:__________________________________________________________________
  20. Date of Birth:____________________________________________________________________
  21. Occupation or School:_____________________________________________________________
  22. Name of Person responsible for account:_______________________________________________
  23. Are you in a private health fund:______________________________________________________
  24. If yes, which one:_________________________________________________________________
  25. We take digital radiographs and pictures in order to investigate and document and to exchange
    information with specialists and technicians. Do you object if we use your pictures unanimously
    and confidentially in presentations and talks?:_____________________________________________
  26. Do you have any allergies:___________________________________________________________
  27. Are you allergic to any drugs:_________________________________________________________
  28. Are you allergic to medication:________________________________________________________
  29. Are you allergic to iodine:____________________________________________________________
  30. Are you allergic to latex:_____________________________________________________________
  31. Are you allergic to jewellery or metal:___________________________________________________
  32. Have you ever experienced prolonged bleeding:___________________________________________
  33. Do you take any medication:__________________________________________________________
  34. Do you take Biphosphonates like Fosamax or Actonel:______________________________________
  35. Are you under any medical treatment:___________________________________________________
  36. Have you had any serious illness:_______________________________________________________
  37. Have you had a heart condition:_______________________________________________________
  38. Do you have high blood pressure:______________________________________________________
  39. Have you ever had rheumatic fever:_____________________________________________________
  40. Have you ever had asthma:___________________________________________________________
  41. Have you ever had diabetes:__________________________________________________________
  42. Have you ever had hyperthyroidism:____________________________________________________
  43. Have you ever had cancer:___________________________________________________________
  44. Have you ever had haemophilia:_______________________________________________________
  45. Do you suffer from, or suspect you may have been infected by, Hepatitis:________________________
  46. Do you suffer from, or suspect you may have been infected by, HIV:___________________________
  47. Do you suffer from, or suspect you may have been infected by, any other infectious disease:__________
  48. Are you pregnant:_________________________________________________________________
  49. If yes, state due date:_______________________________________________________________
  50. Do you intend to get pregnant:________________________________________________________
  51. Your doctor's name and address:______________________________________________________

Please note that we require payment after treatment.

Please give us advance notice if have to cancel an appointment

Signature

Date