New Patient Medical History Form Please complete this form after confirming your appointment. Smile Place clinic location for your appointment.*Forest HillGlen IrisTecomaAre you completing this form on behalf of a dependent?*NoYesName of person completing formThe person completing this form on behalf of a dependent is responsible for validity of the information on this form.Patient InformationPlease make sure you enter the correct values. Some browsers like Safari and Chrome's Autofill feature will sometimes automatically enter incorrect information into the fields. Please check before submitting. TitleMrMrsMsMissDrMasterProfFirst Name*Last Name*Preferred NameGender*FemaleMaleOtherGenderDate of Birth* Email* Will be used to send any information we store to you electronically.Mobile Contact Number*Will be used for to send reminders. Home Contact NumberWork Contact NumberStreet Address*Suburb*Post Code*State*VICNSWTASQLDSAWANTACTOccupationEmergency ContactEmergency Contact Number*Health Fund and MedicareHealth FundHealth Fund Membership NumberHealth Fund Reference NumberMedicare NumberFor patients covered by the Children Dental Benefits Scheme Medicare ReferenceMedicare Expiry DateDepartment of Veterans Affairs NumberWhite and Gold card holders OnlyMedical Doctor (GP) DetailsGeneral Practice*General Practice NameGeneral PractionerName of your GPGeneral Practitioner Contact NumberGP's AddressGP's SuburbGP's Post CodeGP's StateVICNSWTASQLDSAWANTACTMedical HistoryAre you taking any medication?*NoYesMedication Currently TakenMedications for Osteoporosis /Bone Cancer Eg. Bisphosphonates?*NoYesList MedicationsInfections for bone disease?*NoYesInfections for bone disease details:Do you smoke?*NoYesHave you had a joint replacement surgery?*NoYesWhen was the joint replacement surgery?*Are you taking any antibiotics for your joint replacement surgery?*NoYesPrevious history of head and neck radiation therapy?*NoYesAre you pregnant?*NoYesHow many weeks?Please enter a number less than or equal to 50.Are you on contraceptive medicine?*NoYesWhich one? (If known)Have you suffered any of the following?Conditions* Epilepsy Diabetes Rheumatic Fever Asthma High/Low Blood Pressure Haemophilia / Prolonged Bleeding Heart Conditions HIV/AIDS Blood Disease Hepatitis None of the above Have you got any other important health issues?*NoYesPlease Specify any other health issues*AllergiesDo you have any allergies to food, materials or medications?*NoYesPlease specify any allergies*CommunicationHow did you hear about us?* Family or friend Online Search GP or Specialist Football Club Other Sporting Club or Other?Do you wish to receive SMS reminders on your mobile phone?*YesNoPrivacy and ConsentI have read, understood and agree to the above terms.*I agree, I have read and understood the information aboveI authorise the use of the images and videos of x-rays of my face, jaws and teeth both before, during and after my treatment in a practice portfolio to showcase examples of dental work to other patients and my identity will remain anonymous.*YesNoI authorise the use of my images and videos taken of my face, jaw and teeth to be used for marketing material, including websites and printed materials. I understand that if the photographs and/or videos are used, my identity will remain anonymous.*YesNo Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.