Patient Info

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Patient Info

Dear patient, please ensure when completing the Patient Info form:

Select where to send eg Bondi Junction, Dee Why or Hurstville
Complete ALL form fields (if not applicable simply write “NA”)
After clicking SUBMIT wait for the confirmation message that will appear under the SUBMIT button

If after clicking SUBMIT an error message appears, you must go back and make sure all the form fields have been completed (importantly the “Select where to send” at the very top of the form). Then click SUBMIT again.

Select where to send:*
Surname:
Title:
Other Names:
Date of Birth
DD slash MM slash YYYY
Home Address:
Street Address Suburb State Postal Code Country
(H) Ph:
Mobile:
(B) Ph
Email
Emergency Contact:
Relationship:
Emergency Contact Number:
Referring Dentist:
Suburb
Health Fund
HAVE YOU EVER HAD OR DO YOU CURRENTLY SUFFER FROM ANY OF THE FOLLOWING?
Please tick
High Blood Pressure
- Yes
- No
Heart Problems
- Yes
- No
Rheumatic Fever
- Yes
- No
Asthma, chest, or breathing problems
- Yes
- No
Tuberculosis
- Yes
- No
Stomach or bowel problems (eg ulcer)
- Yes
- No
Kidney Disease
- Yes
- No
Diabetes or family history of Diabetes
- Yes
- No
Osteoporosis
- Yes
- No
Thyroid Problems
- Yes
- No
Excessive bleeding or blood disorder
- Yes
- No
Epilepsy
- Yes
- No
Hepatitis
- Yes
- No
AIDS/HIV
- Yes
- No
Arthritis
- Yes
- No
Prolia Injections
- Yes
- No
Do You Smoke
- Yes
- No
How many cigarettes per day
Do You have an artificial hip, heart valve or prosthetic implant?
- Yes
- No
Are you presently taking blood thinner medication?
- Yes
- No
Do you have any allergies?
- Yes
- No
Are you presently under medical care?
- Yes
- No
Are you taking any drugs, medicines or tablets? Please List.
Female patients, are you pregnant?
- Yes
- No
Please list any medicines or products you are allergic to e.g. Penicillin, latex
Have you been in contact with a confirmed COVID case?
- Yes
- No
Have you been vaccinated for COVID-19?
- Yes
- Partially Vaccinated
- Fully Vaccinated
- No
I have completed this Questionaire to the best of my knowledge, and understand that failure to make a full disclosure may place me at undue medical risk. I understand that notes, radiographs (x-rays) or models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and I consent to this. I also give my permission for the practice to use the above contact details to send me appointment and check-up reminders.
Turnstile

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BONDI JUNCTION

Suite 1404
Tower 1, 520 Oxford Street
Bondi Junction NSW 2022
P. 9387 5344
F. 9387 5248
E. bj@sydneyspecialistperiodontics.com.au

DEE WHY

Suite 303
7 Oaks Avenue
Dee Why NSW 2099
P. 99714923
F. 9971 0083
E. dw@sydneyspecialistperiodontics.com.au

HURSTVILLE

Suite 404
12-14 Ormonde Parade
Hurstville NSW 2220
P. 9570 8374
F. 9570 7850
E. hv@sydneyspecialistperiodontics.com.au

Patient Info

Dear patient, please ensure when completing the Patient Info form:

HAVE YOU EVER HAD OR DO YOU CURRENTLY SUFFER FROM ANY OF THE FOLLOWING?

BONDI JUNCTION

DEE WHY

HURSTVILLE