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Last Name

Preferred Name

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Occupation/School

Home Address

Postcode

Phone Number

Mobile Number

Emergency Contact

Doctor/GP

Medicare Card Number

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Health Fund

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How did you hear about our clinic?

Do you smoke?

Pregnant?

Joint Replacement Surgery

Osteoporosis Medication

Special Needs (Please Specify)

Do you require antibiotics prior to dental treatments?

Allergies?

Other Health Conditions

List of your Medication/Supplements

Dental History: (Please Select all Dental Conditions relevant in past 6-months):

Dental Consent:

I disclose that all the information I have completed is accurate and no information has been witheld. I consent to having all dental diagnostics (x-rays, photographs, study models and others tests) deemed appropriate by the dentist to be taken. I also given consent for Accolade Dental to share my health and dental records with other health providers as required. I also understand that payments will be due at the time of service and that I’m soley responsible for all accounts. I authorise Accolade Dental to contact me via post, phone, email and social media about events, specials and practice newsletters.

COVID-19 Status

Have you or the person you are with:

Travelled overseas or interstate and are awaiting COVID-19 test results?

Had close contact with a person who has tested positive for COVID-19?

Have a fever > 37.5oC, loss of smell or taste, cough, shortness of breath, sore throat

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Dental Consent:

COVID-19 Status

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