Medical History Form

Your Health Information and our Privacy Policy

In accordance with the Victorian Health Records Act 2001 and Privacy Act

Our practice respects your right to privacy. We realize that it is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our practice and to whom this information might be disclosed. The policy of our practice is to follow these procedures:

The information collected will be used for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of addressing accounts to you, as well as processing payments and writing to you about your services and any issues affecting your treatment.
We may disclose your health information to other health care professionals, or require it from them if, in our judgment, is necessary in the context of your treatment. In that event, disclosure of your personal details will be minimised wherever possible.
We may also use parts of your health information for research purposes, in study groups or at seminars as this may provide benefit to other patients. Should that happen, your personal identity will not be disclosed without your consent to do so.
Your medical history, treatment records, x-rays and any other material relevant to your treatment will be kept here. You may inspect or request copies of our records of your treatment at any time, or seek an explanation from the dentist. Statutory fees will apply in relation to the types of access you seek. If you request an explanation of our records or a written summary, our usual fees apply to these services.
If any of the information we have about you is inaccurate, you may ask to alter our records accordingly.

You can otherwise rest assured that your health information will be treated with the utmost confidentiality. Disclosure will not be made to any person not involved in either your treatment or the administration of this practice, without your prior written consent. If you have any queries or concerns about our handling of your health information, please do not hesitate to raise these concerns with our practice.

I accept the privacy policy and would like to continue *

Personal Information

Title

First Name (As on Medicare Card) *

Last Name *

Preferred Name?

Mobile Phone *

Phone

Date of Birth *

Address *

Email *

Occupation *

Company

Medical Information

Were you referred? *

YesNo

Referring Doctors Full Name

Please specify

Do you have a Medicare Card? *

YesNo

Name As Displayed on Card

First Name *

Last Name *

Medicare Card Number *

Position on Medicare Card *

Medicare Card Expiry Date *

Next of Kin / Emergency Contact

First Name

Last Name

Phone

Medical Information

If you do not fully disclose all medical conditions or allergies, it can potentially put you at risk of complications following procedures. If you are unsure, please mark YES and this can be further discussed with your practitioner.

Remarks *Please comment on any of the Medical Conditions marked, or add any information you would like the Doctor to know.

HIV *

YesNo

T Cell Count

Hepatitis *

YesNo

Diabetes *

YesNo

Type of Diabetes

III

Other Implants (Within the last 12 months) *

YesNo

Eg Stent, Hip, Knee replacement or Pacemaker

Details and Date of placement

Smoking / Vaping? *

CurrentPastNever

Are you currently smoking?

How many cigarettes / Vape per day?

How many years?

When did you quit?

Are you taking or list any medication taken in the past 30 days? *

YesNo

Please list Medication here: *Including Herbal/Natural remedies List any medication and dosage here separated by ;

Adverse reactions to medications *

YesNo

Please specify

Confirmation

Please sign this form as confirmation that all information provided is accurate and true, and that you accept responsibility for any false information provided. Your health and wellbeing is of the utmost importance to us, and any information no matter how trivial can affect the outcome of the surgery. Adverse effect could occur if information is left out.

If you believe you have missed something go back by using the button below and add the information.

I UNDERSTAND AND AGREE THAT ALL INFORMATION PROVIDED IS CORRECT *

YesNo

Signature *

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