Confidential Medical History Form
✆ (02) 6225 2855
reception@mydentistcanberra.com.au
✆ (02) 6225 2855
⚕ 36/21 Thynne St, Bruce, Canberra - ACT
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Confidential Medical History Form

Confidential Medical History Form

It is important for us to know details about your medical history as these could affect the success of your oral health care. The information provided is confidential and will be handled in accordance with our privacy policy.

Confidential Medical History Form

Your Emergency Contacts

Your Health

Are you interested in whitening?
Are you pregnant?
Any known allergies?
Any known reactions to anaesthesia?
Do you require antibiotic cover BEFORE dental treatment?
Are you taking medication for bone disease?
Please indicate if you have, or have you ever had any of the following medical conditions?
Referred By
Do you consent to your treatment discussions being recorded for treatment planning purposes?

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Get in touch

Phone

02 6225 2855

Email

reception@mydentistcanberra.com.au

Address

36/21 Thynne St, Bruce, Canberra ACT - 2617

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  • Mon - Fri: 8:30 AM - 5 PM
  • Saturday: 9 AM - 5 PM
  • Sunday: 9 AM - 5 PM
  • Public Holidays: Please Call

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