Confidential Medical and Dental History Form

The aim of this form is to assist your dentist in providing you with safe and optimal care.

Completed by Self/Guardian; I hereby apply to become a patient of Adelaide House Dental. I undertake to settle all fees when due either at the time of treatment or in advance. If treatment is to be paid by a third party i.e. under insurance, I remain liable for those fees until the account is settled.