Extended Medical History Form

Watagan Dental Medical History Form

The state of your health may have a significant effect on your dental care. This form is required if you answered "Yes" to any of the trigger questions in the New Patient Form (medications, medical conditions, or disability). Please answer these questions fully or discuss them with your dentist. If the patient is unable to complete this form, a next of kin or legal guardian may fill it out on their behalf.

Patient Information

First name

Last name

Birthday

Month

Day

Year

Weight:

Height:

We need to know your weight and height as our dental chair has a maximum capacity.

Medical Practitioner Information

Name of your medical practitioner (GP/specialist):

Phone Number

Medical Treatment and Hospitalisation

Are you receiving any medical treatment at present?

Have you had a recent visit to hospital?

Medications

If you have knowledge of the current medications being taken by either yourself or the person under your care, please list them below (including dosage and frequency):

Do any of your medications increase the risk of dental treatment? (e.g., blood thinners, bisphosphonates, medications causing dry mouth)

Medical Conditions

Please tick if you have or have had any of the following conditions:

Multi choice

Disability Details

Do you have a disability?

Are you pregnant or nursing?

Lifestyle Factors

Have you ever smoked or vaped?

Yes

No

If yes, have you given up? If yes, how long ago?

Do you consume alcohol?

Yes

No

Care Facility Information (if applicable)

I consent for all medical information, including medication, medical history, and allergies, to be obtained from the Registered Nurse at the Care Facility:

Yes

No

Additional Information

Is there any specific information you would like to provide? (e.g., chipped tooth, family member to attend):

Photography Consent

I authorize and grant Watagan Dental permission to take diagnostic photos of my mouth and teeth to keep as private and confidential records on my Watagan Dental file and for my own personal records:

Yes

No

I grant Watagan Dental permission to use a photo of me on Watagan Dental social media platforms (e.g., Facebook, Instagram) and website. I allow Watagan Dental to edit, alter, copy, or distribute the photos for advertising and marketing. I agree that the

Yes

No

Referral Source

How did you find out about Watagan Dental?

Consent

Have you disclosed all medical conditions you have?

Yes

No

Have you disclosed all medications you are taking?

Yes

No

Have you disclosed all allergies you may have?

Yes

No

Do you agree to urgent treatment if required?

Yes

No

I consent to a dental practitioner providing necessary and recommended services to myself or the person I consent for. I acknowledge that I am financially responsible for the costs of this treatment:

Yes

No

Consentee Details

Are you consenting for yourself?

Yes

No

If you are not the person receiving treatment, are you the person responsible for medical and dental consent for the patient requiring treatment?

Yes

No

If you are consenting for someone else, please provide your details:

Full Name

Relationship to Patient

Email

Phone Number

Signature

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