Patient First Name *

Patient Last Name *

Date of Birth *

Your Email *

Medical History

Please tick the appropriate boxes.

Abnormal/excessive bleeding	Cancer	MS
Angina	Cardiac surgery/pacemaker	Nervous disorder
Artificial heart valve	Congenital heart defect	Oral ulceration
Asthma	Diabetes type 1/type 2 - specify in medical notes	Prosthetic joints
Blood disorder	Epilepsy	Psychiatric care
Heart disease	Radiation therapy	Chemotherapy
Blood pressure (high/low)	Heart murmur	Reflux
Blood thinner	Hepatitis A/B/C/D - specify in medical notes	Rheumatic fever
Bone disease (e.g. Osteoporosis)	HIV positive	Steroid therapy
Kidney disease	Liver disease	Thyroid disorder

Any other medical notes?

Are you pregnant? YesNo
If so, due date?
Are you taking medication (including natural supplements)? YesNo
If so, please list:

Allergies

Aspirin	Iodine	Latex
Penicillin	Sulpha drugs	Other (please specify)

Privacy policy and signature
Any information is collected and maintained in accordance with State and Federal Privacy Legislation. A copy of our privacy policy can be obtained online at www.edentistry.net.au. I have accurately completed this medical history form to the best of my knowledge.

I hereby give my authority for any treatment agreed upon by me, to be carried out by the dentists and staff at eDentistry Wantirna. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made.

I authorise my dentist to take images of my teeth both before and after my treatment. I understand these images may be used in a practice portfolio to showcase examples of dental work to other patients and my identity will remain anonymous.

Your Healthcare Rights
The Australian Charter of Healthcare Rights describes the rights of patients and other people using the Australian health system. These rights are essential to make sure that, wherever and whenever care is provided, it is of high quality and is safe.

Access – You have a right to health care.
Safety – You have a right to safe and high quality care.
Respect – You have a right to respect, dignity and consideration.
Communication – You have a right to be informed about services, treatment, options and costs in a clear and open way.
Participation – You have a right to be included in decisions and choices about your care.
Privacy – You have a right to privacy and confidentiality of your personal information.
Comment – You have a right to comment on your care and to have your concerns addressed.

For more information on the Charter, visit www.safetyandquality.gov.au.

Existing Patient Update Form