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.


Please rest assured that you will receive the very best of care at our practice. We take all recommended precautions to ensure the health and wellbeing of our patients and our staff and we ask for your assistance as follows:

  • It is essential that you provide your medical history, referral and x-rays in order to have your appointment confirmed. If you are experiencing difficulty with this, please call us as soon as possible.
  • If at any time before your appointment you are unwell (eg fever, cough, sore throat, respiratory issue, etc) OR test positive to COVID-19, please call us before attending the practice to discuss this.

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
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