Registration

Title Mr.Mrs.Miss. First Name Last Name

Date of Birth Occupation/School

Address
Suburb Postal Code

Email
Telephone Home Mobile Work

Next of kin name and contact details in case of emergency need

Name of Doctor/Medical Practice

Are you taking any prescription or non-prescription medication, pills, or inhalers? YesNo
If yes, please list:

Have you ever had any allergies to medications or other substances (e.g.Latex) YesNo
If yes, please list :

Have you ever had any of the following:
Heart Murmur YesNo
Open heart surgery YesNo
High or low blood pressure YesNo
Rheumatic fever YesNo
Other heart trouble/stroke YesNo
Asthma YesNo
Chest/lung/breathing problems YesNo
Eczema YesNo
Epilepsy YesNo
Radiotherapy or Chemotherapy YesNo
HIV/Hepatitis B or C YesNo
Diabetes YesNo
Tuberculosis YesNo
Bruising or blood disorder YesNo
Other infectious diseases YesNo
Depression/anxiety or stress YesNo
Smoker YesNo
Any artificial joints YesNo
Any Bisphosphonate medications, including Fosamax YesNo
Any excessive bleeding from previous surgery or dental treatment YesNo
Any reaction to anesthetic YesNo
Women: Are you pregnant or breastfeeding? YesNo
Any other health matters that you think you should let the dentist know:

I confirm that the information provided above is true and correct to the best of my knowledge.

Name of patient/parent/guardian Date