New Patient

Medical History Questionnaire

Medical History Questionnaire

It is important for your dentist to have your medical history and understand your health needs before any examination or treatment is carried out. Medical information will be kept strictly confidential and in accordance with the Privacy Act 1988.

Your Personal Details

Details of Contact in Case of Emergency

Medical Questionnaire - Private and Confidential

Please answer these questions to the best of your ability or discuss them with your dentist, information about your medical history is for your dentists use only and will help your dentist delivery optimal care to you

Please indicate if you have EVER had any of the following?

Dental History

Are you interested in any of the below treatment options?

Responsible Party for Payment

I agree that the above is a true and accurate record. Payment on the day is required. Any expenses, costs or disbursements incurred by Encounter Bay Dental & Implants in recovering any outstanding monies including debt collection fees and solicitor costs shall be paid by the responsible party above. I further acknowledge that failure to attend any appointment without notice may result in a failure to attend fee.
PLEASE NOTE: This medical history questionnaire and ensuing clinical records will be electronically copied to your clinical record file and the original will be subsequently destroyed. By signing this document, you agree to this process. this form is a guide only and you should discuss any relevant matters with your dentist prior to the commencement of any dental treatment. Orthopantomogram (OPG) and Cone Beam CT (CBCT) if needed will be taken at your initial visit. These films are not reported on by a radiologist, we predominantly will be focusing on dental pathology.

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 Anton Nicosia 
 
 
 Anton Nicosia 
 
25/11/2022
 
 
  
Great dental team - friendly, helpful & explained everything to me.
  
 
  
 
 
 
 Christa Michaelis 
 
 
 Christa Michaelis 
 
11/07/2022
 
 
  
I had a tooth fitted with a crown today, following removal of an old filling. This was the second crown i had done here within eight months, in between I had my teeth cleaned and a filling as well. I can't speak highly enough of all the team members I have met, -dentists, technicians and reception staff. Everybody is friendly and competent.  Procedures are carried out gently and painlessly, with a lot of consideration for patient comfort. A very impressive 3-D-printer-like piece of machinery (see picture) enables the team to manufacture crowns in-house which means you don't have to attend twice. Can't wait to go back - already booked my next appointment ! πŸ˜‰
I highly recommend Encounter Bay Dental to anyone in need of dental work!
  
 
  
 
 
 
 Brian Thorpe 
 
 
 Brian Thorpe 
 
04/06/2022
 
 
  
Very good experience. Had root canal work done on infected tooth. Was able to get in the day after I phoned for an appointment. Would have had to wait 2 weeks to get in to see local dentist. Dentist very professional and explained procedure being done. Will definitely change to this dentist for any future work.πŸ‘πŸ‘πŸ‘
  
 
  
 
 
 
 julie jordan 
 
 
 julie jordan 
 
14/04/2022
 
 
  
Was fitted in at short notice with a very troublesome tooth. I can’t speak more highly about every aspect of the care taken & attention given to a fairly complex situation. Top notch! Highly recommended & I’ll be back!
  
 
  
 
 
 
 Cindy Headon 
 
 
 Cindy Headon 
 
13/12/2021
 
 
  
Professional, compassionate an EXCELLENT Customer Service.
"It's a YES from Me" !!!
Thank you so very much Georgia and Cipi. With thanks so very much and Regards,
Cindy πŸ˜†πŸ˜†πŸ˜†
  
 
  
 
 
 
 Mork 
 
 
 Mork 
 
25/10/2021
 
 
  
I am a new client as we just moved in down the road and so very happy with the quality of the work and all the staff where wonderful. Cheers
  
 
  
 
 
 
 Ramsey June 
 
 
 Ramsey June 
 
02/10/2021
 
 
  
Had a really good experience, no fuss got the job done, friendly dentist, would recommend
  
 
  
 
 
 
 
 
 
 Google rating score: 4.0 of 5, based on 12 reviews