Confidential Patient Information Record

Welcome to Captivate Dental
To assist us in providing the best dental treatment for you, please answer the following questions as completely as possible.

PERSONAL INFORMATION

Title

MrMrsMsDr

First Name

Surname

Preferred Name

Date of birth

Street Address

Suburb/Town

Postcode

Telephone (Home)

Mobile

Telephone (Work)

Email

Occupation

Name of person responsible for fees

Address(if different from above)

Emergency Medical Contact

Emergency Contact Telephone

Do you have dental insurance?

YesNo

Name of fund

NOTICE TO INSURED PATIENTS REGARDING DENTAL BENEFITS INSURANCE.
Item numbers on our statement represent as accurately as possible the procedures performed but in no way are they a claim on anyone other than the patient for whom they were performed. The eligibility of the patient, or the procedures, to attract refunds, and the rates of those refunds, are determined by the condition of the patient’s Health Insurance Policy. We accept no responsibility to either party, for any decision the insurer may make regarding the refund of monies to the patient.

Who referred you to our dental practice?

MEDICAL INFORMATION

Name of Medical Doctor

Medical Practice Address

Postcode

Telephone

Email

Have had any previous illnesses not mentioned above?

YesNo

Please list

Would you prefer to discuss these in private with the Dentist?

YesNo

Are you pregnant?

YesNo

Due date

Have you ever been advised to take antibiotics before dental treatment?

YesNo

Are presently under medical care or taking any prescribed medicines or tablets?

YesNo

Please list

Please list any medicines or products you are allergic to

Do you have any other allergies?

YesNo

Please list

Are you currently taking any other non-prescription medication?

YesNo

Please list

DENTAL INFORMATION

To assist us in providing the best dental treatment for you, please answer the questions relevant to you.

What is your reason for today’s visit?

What year was your last dental visit?

When was your last dental clean?

Have you ever had dental x-rays?

YesNo

When were your last x-rays?

What dental work was performed at your last visit?

Previous dentist’s name

Previous dental practice address

Are there any other dental problems that concern you?

YesNo

Please list

Are you experiencing any discomfort?

YesNo

Please explain

Are you aware of bad breath or bad taste in your mouth?

YesNo

Do you clench or grind your teeth while awake or asleep?

YesNo

Have you had a splint made to prevent grinding, clenching or snoring?

YesNo

Do you have difficulty chewing on either side of your mouth?

YesNo

Which side of the mouth?

Are you aware of any problems with your jaw joints (eg pain, clicking and/or scraping, locking & limited movement)?

YesNo

Do you play a sport that requires a mouthguard?

YesNo

Do you drink tea or coffee?

YesNo

Do you smoke or vape?

YesNo

Would you like to make your teeth whiter?

YesNo

Would you want to make your teeth straighter?

YesNo

Do you feel that you need to close spaces or replace missing teeth?

YesNo

Is the long term health of your teeth important to you?

YesNoDepends on cost

PATIENT DECLARATION

I have completed the above questionnaire to the best of my knowledge and understand that failure to make a full disclosure may place ME at undue medical risk. I have been issued a copy of the Captivate Dental Clinic Privacy Policy and consent to the use of my health information in this way.

Print Name

Date

Signed

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