www.smileinstyle.com.au - Medical History Update Form

Medical History Update Form

Please note that it is important to fill in all the fields before submitting. Thank you.
Patient Information
Title
Gender
If "Other" Please Specify
Patient Name

First NameMiddle NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Home Address

Street Address Line 2

City

Postcode
Suburb

Suburb

Street Address Line 2

City

Postcode
State
Postcode

Street Address Line 2

City

Postcode
Home Phone Number
Mobile Phone Number
Work Phone Number
Email Address
example@example.com
Occupation
Health Insurance
Member ID Number
Contact person in case of emergency
Phone/Mobile Number
Would you like to subscribe to our newsletter?
Medical History
Are you being treated for a medical condition?
If Yes, Explain
Medical Doctor's Name

First NameLast Name
Doctor’s Address

Street Address Line 2

City

Postcode
Suburb

Street Address Line 2

City

Postcode
State
Postcode

Street Address Line 2

City

Postcode
Phone Number
Are you taking any medications or supplements at present, both prescribed or over the counter?
If Yes, Please list
Are you taking any bisphosphonate medication or any other medication to treat osteoporosis?
If Yes, Explain
Do you have, or have you ever had, any of the following medical conditions?

Other
Do you have allergies?
What reaction do you have to allergies, please list.
Do you smoke?
How many /day?
Do you Vape?
If so, how often
Are you pregnant or undergoing fertility treatment?
If Yes, Explain
Guardian Name

First NameLast Name
Dependents
Your Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Please verify that you are human
Should be Empty:

Medical History Update Form

Patient Information

Medical History