Client Acquaintance Form Client Acquaintance Form Title * First Name * Last Name * Email Address * I Prefer to be Called: * Date Of Birth * Mobile * Home Phone Work Phone Preferred Contact No * MobileHomeWork Are you happy to receive information via email (surveys, special offers etc) How would you like to receive appt reminders? Copy * Text/SMSPhoneEmail Address (Residential) Address (Postal) Do you have Private Health Insurance with Dental Cover? * YesNoUnsure If yes, which fund? Are you eligible for Medicare CDBS Scheme? (patients 2 – 18 years old) * YesNoUnsure If yes, please advise reception prior to the appointment. Medical Doctor Name Contact Number Emergency Contact Contact No. Relationship to you How did you find out about our clinic? * Google / WebsiteFacebookInstagramWOMO OnlineYellow PagesMt Eliza Magazine Friend or Family (please list name) Other Are you Pregnant? * YesNo Are you currently Breast feeding? * YesNo Do you Smoke? * YesNo Do you Snore? * YesNo Play contact sports? * YesNo Please list any allergies (Medication, Penicillin, Latex etc) Please list any medications (including herbal and prescribed) Have you EVER had any of the following Heart MurmurRheumatic FeverArtificial JointsAsthmaHepatitis (A, B or C)HIV / AIDS Do you now or have you recently suffered from any of the following Excessive BleedingCancer/TumourThyroid problemsHeart PacemakerRadiation TherapySinus TroubleFainting/DizzinessChemotherapyArthritisRespiratory DiseaseLow Blood PressureStomach ProblemsHealing ComplicationsHigh Blood PressureBowel ProblemsDiabetesStrokeDepressionHeart SurgeryKidney DiseaseLiver DiseaseNervousnessHeart diseaseBlood diseaseAnxietyChest PainEpilepsyPsychological Disorders Other medical details to be included? Are you experiencing any of the following Sensitivity to cold or hotBleeding GumsClicking of Jaw JointsPainful teeth when bitingHead/Neck AcheMouth UlcersRoughness of teethBad Taste or Bad BreathJaw Clenching or grindingFood Trapped between teethStained Teeth or FillingsDry Mouth Consent for Services To the best of my knowledge, the preceding answers and all information provided are true and correct. Should I have any change in my health status or personal details, I will inform the doctor at my next appointment, without fail. I understand that notes, radiographs (x-rays) or models relating to my treatment may need to be sent to other practitioners to aid them in my treatment and consent to this. I understand that dental treatment must be paid in full at the time of treatment. I acknowledge that if an account is overdue The Smile Place Mt Eliza reserve the right to refer the account to a third party. I agree to meet all reasonable costs incurred by The Smile Place Mt Eliza in employing the said third party, to collect the overdue account. I understand that if I do not give at least 24 hours’ notice a cancellation fee may be charged. I Accept * YesNo Your Name Relationship to child if Parent or Guardian Date
