• Confidential Medical and Dental History Form

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

  •  -  - Pick a Date
  • Are you?

  • Have you?

    (as a child or adult)
  • Do you?

  • PAST DENTAL HISTORY

  • WOULD YOU LIKE TO KNOW MORE ABOUT ANY OF THE FOLLOWING

  • 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.

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  • Should be Empty: