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Welcome to michael adams’ rooms

WELCOME TO ADAMS DENTAL WOULD YOU PLEASE FILL OUT THIS FORM
PERSONAL DETAILS
(Dr Mr Mrs Miss Ms) Surname:______________________________________________________
Christian Names: _____________________________________________ D.O.B:________________
Private Address:____________________________________________________________________
Postal Address: ____________________________________________________________________
Occupation: _______________________________________________________________________
Home:____________________ Business:____________________ Mobile:_____________________
Email Address______________________________________________________________________
Who is responsible for this account? ___________________________________________________
Who can we thank for recommending you to this practice?_________________________________
Are you covered by private health cover?
If yes, which fund ___________________ Patient Number on your card next to your name 00 / 01 / 02 / 03 / 04 / 05 / 06 Reason for your visit today? (e.g. tooth ache, check up, clean, aesthetics) _________________________________________________________________________________ Are you interested in? TEETH WHITENING AMALGAM REMOVAL DENTAL IMPLANTS VENEERS When did you last visit your dentist?___________________________________________________
MEDICAL INFORMATION
Who is your medical practitioner? _____________________________________________________
Are you a smoker? (please circle) NO EX-SMOKER SOCIAL MODERATE HEAVY
Are you taking ANY medication or supplements? (Including but not limited to contraceptive pill, vitamins,
dietary supplement, asprin, warfarin, fosamax)
_________________________________________________________________________________
Please list ANY allergies to food or medicines? (e.g. Antibiotics, Codeine, Milk Products)
_________________________________________________________________________________
Ladies, do you think you may be pregnant? (please circle)
Do you have ANY medical conditions?
Please specify or add any relevant details: _________________________________________________________________________________ Signed:______________________________________________ Date:______________________ Thank you for providing this important information which will remain part of your personal and

Source: http://adamsdental.com.au/wp-content/themes/twentythirteen/images/medical_history.pdf

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