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 your privacy is important to us. The Endodontic Group collects and deals with your information in accordance with our Privacy PolicyCharter of Patient Rights & Disclaimer.

Before starting this form, please have on hand details of any medications you are currently taking. We encourage you to complete and submit the form within an hour to ensure successful submission. Please do not move off this page or open a new tab while completing the form as you may lose data you have already entered.

AN IMPORTANT COVID-19 MESSAGE FOR PATIENTS

Please rest assured in these uncertain times that you will receive the very best of care at our practice. We are taking all recommended precautions to ensure the health and wellbeing of our patients and our staff and we ask for your co-operation in the following ways:

If you are a COVID-19 close contact, you may attend your appointment if you are not symptomatic. Please ensure you follow the Qld Health guidelines for close contacts.

ON THE DAY OF YOUR APPOINTMENT

  • If you have not yet submitted your medical history form please arrive at least 15 minutes prior to your appointment. 
  • On arrival, you will be asked to wash or sanitise your hands and carry out a pre-appointment mouth rinse.

We thank you for your assistance. You are in excellent hands with our specialist team and we look forward to welcoming you to our practice.

To ensure data security, we prefer you to complete and submit our online medical history form below. If you are unable to complete this form online, please use this printable medical history form.

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

Your Details

Preferred Name
Home Phone
Work Phone
 
Occupation
If not known, please type unknown.
Please list any other medical or dental practitioners your treatment records can be released to if requested
Attach Referral, X-Rays or Photos (if not already supplied)
Must be JPG, GIF, PNG, TIFF, PDF, DOC or DOCX files no larger than 3MB with only - and _ characters in file names.

Drop multiple files at once or