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:

  • 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 the following applies to you, please call us before attending the practice to discuss this:
    • you experience or have close contact with anyone experiencing a sore throat, fever, cough or respiratory issues
    • come into close contact with anyone who has been diagnosed with COVID-19 or has been asked to self-isolate in the past 14 days
    • come into close contact with anyone who has returned from overseas in the past 14 days
  • Unless you are a carer or guardian, please don't bring other people with you to the practice waiting room.
  • Please arrive 5 minutes prior to your scheduled appointment, but no earlier than that.
  • If you are travelling from NSW for treatment, you will need to apply for a border pass (Compassionate entry) and we will email you a letter the day before your appointment which you may need to show at the border. Please allow additional travel time.
  • On arrival, you will be asked to wash or sanitise your hands at our practice. Your temperature may also be taken and an anti-viral mouth rinse may be requested.

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.

  • 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.
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