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New Patient Form

Preferred method of communication

I am happy to receive the following communications:
Product & Service Information or PromotionsNewslettersImportant Notifications

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) - specify in medical notes 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:


Aspirin Iodine Latex
Penicillin Sulpha drugs Other (please specify)

Dental History
Have you ever had a reaction or complication following dental treatment in the past? YesNo
    If so, please detail:

Is there anything else the dentist or hygienist should be aware of?

Are you suffering from any of the following?

Bad appearance of teeth Discoloured teeth Lost filling/cavity
Bad breath Dry mouth Rapidly decaying teeth
Toothache Bleeding gums Missing teeth
Sensitive teeth Worn or broken teeth Difficulty chewing
Loose teeth Sounds/pain from jaw joint Unsatisfactory denture

Have you ever had a sleep study and been diagnosed with sleep apnoea?YesNo
If yes, have you ever tried Continuous Positive Airway Pressure (CPAP) therapy?YesNo
Has anyone ever told you that you snore?YesNo
After 6-7 hours of sleep do you wake up refreshed?YesNo

How did you find out about eDentistry Wantirna?

On a scale of 1-10, with 10 being very comfortable and not at all anxious, how comfortable are you feeling about your upcoming appointment?


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 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

We are currently still under restrictions, but can see patients for all necessary treatment WITH THE EXCEPTION OF regular maintenance (i.e. cleaning). Contact us for more information
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