New Patient Medical History Form

New Patient Medical History Form

Welcome to Ringwood Dental. Please fill in as much information about yourself that you are able to.

Dental History
Allergies to penicillin or any other medication, metals, or latex?*

YesNo
If so, please list:*
Do you currently have, or have you recently been exposed to an infectious disease?*

YesNo
If so, please list:*
Have you been vaccinated against COVID19 and if so how many doses have you had?*

YesNo
If so, please list:*
Any current medications or treatment?*
Have you ever taken medication for bone cancer or osteoporosis?*
How long has it been since your last dental visit?*
Purpose of visit today?*
Are you unhappy with your smile?*

YesNo
If so, please describe:*
Declaration

I understand that all information provided is kept private and confidential. I have completed this questionnaire to the best of my knowledge and understand that failure to make a full disclosure may place me at undue medical risk. I agree to allow the treating dentist to discuss my medical and treatment details with other treating practitioners outside the practice, to whom I may be referred for specialist treatment.
Signature*
ALL ELECTRONIC HEALTH FUND CLAIMS ARE REQUIRED TO BE PROCESSED ON THE SAME DAY OF SERVICE.

WE EXPECT AND APPRECIATE PAYMENT AT TIME OF SERVICE.
Date of Consent

DayMonthYear
Send a Copy To Self

Yes
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