New Patient Form

Please note: Private Health Rebates may not apply to all items depending on the treatment protocol.

Veteran Affairs DVA No.

Relationship to patient

How did you hear about Pacific Biological Dentistry?

Medical History: Do you have, or have you had the following:

Heart disease

Yes No

High blood pressure

Yes No

Hepatitis or other liver disease

Yes No

Valve Disorder

Yes No

Cardiac Pacemaker

Yes No

Nervous condition/anxiety

Yes No

Creutzfeldt-Jakob Disease

Yes No

Emphysema or other lung disease

Yes No

Stomach or digestive condition

Yes No

Steroid Therapy

Yes No

Rheumatic Fever

Yes No

Prosthetic e.g. Shunt

Yes No

Kidney Disease

Yes No

Thyroid Disease

Yes No

Radiation or Chemotherapy

Yes No

Hashimoto’s

Yes No

Leukaemia or other blood disease

Yes No

Excessive Bleeding

Yes No

Contact with HIV/AIDS

Yes No

Medication And Supplements

How Long Taken For And Dosage

Are You Being Treated By A Doctor (Naturopath or Integrated Dr) At Present

Yes No

If Yes, Please Provide The Name Of Your Doctor?

Drug Allergies (Penicillin, Etc.)

Food / Other Allergies

Latex Allergy?

Yes No

Do You Normally Require Antibiotic Cover Before Dental Treatment?

Yes No

Have You Had Any Abnormal Reactions To Local Anaesthesia?

Yes No

For Women, Are You Pregnant Or Breastfeeding?

Yes No

Lifestyle Questions: Please Indicate If Relevant:

Smoke Cigarettes?

Yes No Have in the past

If Yes, Daily amount?

Recreational Drugs

Yes No Have in the past

Covid- 19 Vaccination Questions: Please Indicate If Relevant:

I have had a Covid-19 Vaccine

Yes No Prefer Not To Say

Dosage?

First Dose Second Dose Booster

If Yes, What Type Of Vaccine And How Long Ago?

Did You Have Any Adverse Reaction To The Vaccine?

As part of your treatment a photographic record may be made, that is X-rays and clinical photographs.

Have you had any X-rays, etc, within the last year? (If yes, we will contact you to complete a release of records form to receive prior to your appointment)

Yes No

These will be kept with your notes and will be held in confidence as part of your medical record. These are not used for advertising or social media purposed.

I give consent for diagnostic photo/s If required I give consent for x-rays (Private fee (Item 022) $60.00 ea. and OPG (Item 037) $135.00)

Privacy And Consent Statement

Pacific Biological Dentistry operates in accordance with and is bound by the National Privacy Principles under the Privacy Act 1988 (‘NPPs’). The NPPs govern the ways that we collect information from you that is necessary for use to attend to your dental heal care requirements. The NPPs also govern the way we store this information in your dental records, how we use that information and how you may have access to your records.

Client Details

Please note: Private Health Rebates may not apply to all items depending on the treatment protocol.

Incase Of Emergency

Medical History: Do you have, or have you had the following:

Medication And Supplements

Allergies

Lifestyle Questions: Please Indicate If Relevant:

Covid- 19 Vaccination Questions: Please Indicate If Relevant:

As part of your treatment a photographic record may be made, that is X-rays and clinical photographs.

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