Complete the required forms online prior to your appointment.


Alternatively you can use the download links below to print and complete forms.


Submit Form online



Medical History

  • Your answers will help our surgeons provide you with the most appropriate treatment
  • The information you give is strictly confidential
  • Your honesty may assist in avoiding health problems


  • UnsureNoYes
    If yes, please tick where appropriate
    Heart diseaseHigh blood pressureRheumatic feverAsthmaDiabetesKidney diseaseHepatitisEpilepsyAnaemiaOsteoporosisOther prolonged illness, please give details

  • UnsureNoYes
    If yes, please tick where appropriate
    PenicillinPain killersIodineAnti-inflammatoriesCodeineLatexOther medication/drug/substance, please give details

    Reactions: RashSwellingVomitingOther, give details

  • UnsureNoYes


  • UnsureNoYes


  • UnsureNoYes

  • UnsureNoYes


  • UnsureNoYes
    If yes, please tick where appropriate WarfarinAspirinPlavixAny other blood thinning medication

  • UnsureNoYes

  • UnsureNoYes

  • UnsureNoYes
    0-55-1010 or more

  • UnsureNoYes
    < 1020-3030-60More

  • UnsureNoYes

  • UnsureNoYes

  • UnsureNoYes

  • BroadmeadowForster, Maitland or Port Macquarie


  • Additional Information Required

  • NoYes


  • Parents Details

    Accounts for patient will be issued under parents name.






  • HospitalDental/Extras






  • Dentist (as above)GP (above)Other (please enter details below)
  • Privacy Policy

    We respect your privacy

    In order to provide you with the highest standard of oral surgery care, this Practice is required to collect personal information from you. This information covers basic details such as your name, address and telephone number but it is also necessary to obtain from you details regarding your general health and past medical or surgical events. Without this general health picture, the treating Practitioner is unable to plan your care properly.

    Naturally, some of this information is of a personal nature and some of it might be regarded as “sensitive” and not the sort of information that you wish to be unnecessarily disclosed to others.

    We value the need to safeguard this information and, in accordance with the principles laid down in privacy legislation and the guidelines issued by the Australian Dental Association, we would like to assure you that:

    This information will only be issued by the treating Practitioner in order to deliver your care to the highest standards.
    It will not be disclosed to those not associated with your treatment, without your express consent.
    You may seek access to the information held about you and we will provide this access without undue delay. This access might be by inspection of your records at the time of your appointment or by special access or copying of information.
    There will be no charge for requesting this information but there may be fees levied just to cover the costs associated with the processing of this request for copying information.
    We will take all reasonable steps to ensure at all times that the details we keep about you are accurate, complete and up-to-date.
    We will take all reasonable steps to protect this information from misuse or loss and from unauthorised access, modification or disclosure.
    Our staff are trained to respect these principles at all times.
    If you have any questions regarding the information we collect from you and hold in your records at this Practice, please do not hesitate to ask us. We are acting in your interests at all times.


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