Your medical history can affect the success of your dental treatment and will guide us on how to provide safe treatment for you. The information you provide is completely confidential and will be handled in accordance with our privacy policy.

Please complete your details below and submit the form. If you’d like to receive a copy of this information simply enter your email address. If you’d prefer to complete this form offline, please arrive at the practice 10 minutes before your scheduled appointment to fill out your medical history.

  • Step 1 - Details
  • Step 2 - Emergency Contact
  • Step 3 - History
  • Step 4 - Medications

Your Details

Preferred Name
Home Phone
Work Phone
 

Required for copy to be emailed to you
Occupation
If not known, please type unknown.