Medical History Form

Are you receiving any medical treatment at this present time?
YesNo

Have you experienced allergies or unusual effects from any tablets, injections or anaesthetic?
YesNo

Have you ever had any of the following?

Heart Problems

Blood Pressure

Artificial joints

Rheumatic fever

Circulatory problems

Radiation Treatment

Excessive Bleeding

Excessive Bruising

Ulcers (stomach)

Anemia or other blood disorders

Diabetes

Asthma

Hepatitis A,B,C,D,E

Epilepsy

Liver Problems

Kidney Problems

Sinus Trouble

Cancers/Tumours

Details of person to contact in an emergency:

Dental Questionnaire
Are you a smoker?

Do you become anxious or uncomfortable when you are having dental treatment?
YesNo

Do you brush and floss daily?
YesNo

Do you grind or clench your teeth?
YesNo

Do you experience any sensitivity with hot/cold?
YesNo

Is there anything with your teeth that you are unhappy about?
YesNo

How would you rate your smile on a scale of 1 to 10? (10 being perfect)

Is there anything else you would like the dentist to know?
YesNo

I understand that if I fail to give 48 hours notice to cancel my appointment, that a fee may be charged. I agree to be responsible for payment of all services rendered on my behalf, and on the behalf of my dependents understand that this payment is due at the time of service unless other arrangements have been made.

Medical History Form

We Accept all Health Funds

We have 4 Payment Plans Options Available for Our Patients in Warner

Let’s start your smile journey now.

Complete the online form above or download the PDF file here

Quick Links

For new patient enquires:

Opening Hours

Areas We Serve

Monday	8:30 am – 7 pm
Tuesday	8:30 am – 5 pm
Wednesday	8:30 am – 5 pm
Thursday	8:30 am – 5 pm
Friday	8:30 am – 5 pm
Saturday	8:30 am – 2 pm
Sunday	Closed