Title DR MISS MR MRS MS
First Name *
Last Name *
Preferred Name
Date of Birth *
Home Address *
City *
State *
Postcode *
Email Address *
Work Phone Number
Home Phone Number
Mobile Phone Number *
Occupation *
Name *
Phone *
Person Responsible for fees * Self Other
Address *
Post Code *
Yes No
Dental Hospital
Which Fund?
Rheumatic Fever Hepatitis Lung disease Asthma Heart problems Pacemaker Digestive problems Diabetes HIV/Aids Anxiety Nasal problems Sleep apnea Back problems Stroke Infectious diseases Osteoporosis Neurological problems Epilepsy
Any major surgery in last 5 years?
Are you pregnant or hoping to be so? Yes No
If so, how many weeks?
Do you smoke? -- Please select -- Yes No
If Yes how many per day?
Any other relevant medical history?
Do you have any allergies? -- Please select -- Yes No
If Yes state allergy
Emergency plan
Please indicate any medications that you are currently taking or have taken recently (including natural therapies).
Have you had previously?
Orthodontic opinion: -- Please select -- Yes No
Orthodontic treatment -- Please select -- Yes No
In your own words, what concerns you about your teeth, OR What is the purpose of your visit?
Who is concerned about your teeth and/or jaws? -- Please select -- Self Your partner/family Your dentist No one
Is this consultation related to Work related injury or Transport Accident? -- Please select -- Yes No
If Yes, when was the accident/injury?
Do you have a history of trauma to the teeth or jaws? -- Please select -- Yes No
If Yes, when was the accident and injury?
Is there anything you want to discuss with Dr Yusupov in private? -- Please select -- Yes No
Name of Dentist
Location
Date of last check up
Recommended by
Email Reports to you -- Please select -- Yes No
Email reports to dentist -- Please select -- Yes No
Email reports to specialists -- Please select -- Yes No
Can we SMS appointment reminders to you? -- Please select -- Yes No
Terms & Conditions * I agree to be responsible for all payment of fees and understand that payment is due at the time of the service
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