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
    • you or someone you have come into close contact with have/has been diagnosed with COVID-19 or asked to quarantine or self-isolate in the past 14 days
    • you travel to or come into close contact with anyone who has returned from overseas or a known interstate hotspot or lockdown area 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.
  • If you have not yet submitted your medical history form please arrive a minimum of 15 minutes prior to your appointment. If you have submitted your medical history form already please arrive 5 minutes prior to your scheduled appointment, but no earlier than that.
  • If you're entering Queensland for treatment, please visit the QLD Government border restrictions page for up-to-date information on whether you require a Qld Border Declaration Pass, eg. you've visited a State with a hotspot in the past 14 days. We encourage you to carry valid photo ID and allow for travel delays at the border, remembering that your appointment is on AEST/QLD 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.

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.
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