Medical History Form
Patient Details
Your Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
N/A
Parent / Guardian # 1
*
First Name
Last Name
Your best contact number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Parent / Guardian # 2
First Name
Last Name
The best contact number
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State
Post Code
Where is your child's Day Care Centre located?
Name of centre
Suburb
Private Health Insurance if applicable
Name of Fund
Membership Number
Person Number (on back of card)
Medicare Number
*
Medicare Number 10 didgits
Individual Reference Number (which person on the card eg. 1, 2, 3)
Expiry Date
Do they qualify for the Child Dental Benefit Scheme CBDS?
*
Yes
No
Unsure
I give consent for Tooth Fairy Dental to check my child’s eligibility for the Child Dental Benefit Scheme with Medicare.
*
Yes
N/A
Are they currently taking any medication?
*
Yes
No
Please list any medications, supplements and vitamins
Do they have any allergies? eg Latex, Penicillin, Milk Protein
*
Yes
No
If yes, please specify. Please list any allergies include band aids, bees, dust ect.
Have they ever had any of the following conditions?
*
Asthma
Snoring/Sleep disturbance
Epilepsy
Excessive Bleeding
Rheumatic Fever
Heart problems
Cancer treatment
Hepatitis
ENT surgery
None of the above
If yes, please specify
Do they have any other conditions such as?
*
ADHD
Developmental Concers
Autisum
Other
Behavioural Conditions
None of the above
If yes, please specify
Does you child use a dummy or suck their thumb or fingers?
*
Yes
No
Do you have concerns regarding your child's speech?
*
Yes
No
Are you happy for them to recieve a recommended topical fluoride or remineralisation treatment?
*
Yes
No
Remineralisation treatment/no fluoride
Are you happy for us to take pictures of our visit to the Day Care Centre?
*
Yes
No
How would you like to pay?
*
Invoice to be emailed to claim on my child's Private Health
CBDS - Bulk billed if applicable
Privately billed - I don't have private health or qualify for CBDS
Is there anything you would like us to discuss with your child regarding their oral health?
Is there anything you would like us to know about your child?
Is there anything you would like to discuss with us? Any questions or comments?
Declaration
I the Parent/Guardian acknowledge that the above information is accurate and I consent to the educational program, dental screening examination and topical remineralisation treatment if stated above.
Signature
Submit
Should be Empty: