Online Patient Questionnaire-Bays Dental

Patient Health Questionnaire

Please complete the form below
First Name *
Surname *
Gender *
Phone Number

Area Code Phone Number
Mobile Number *

Area Code Phone Number
Date of Birth *

Day Month Year

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail Address *
NHI Number
School (if under 18 years)
Full name of school
Medical Insurance Name & Membership Number
example: Southern Cross. membership number 123123123
Have you previously attended our practice? *

Yes No
We use the above contact details to remind you of your appointments/alert you when you are due to book. It’s also used to notify you of special promotions or competitions via our newsletter. * *

Yes No
How did you hear about us? *

Google Website Radio- The Breeze Radio- Life FM Road Sign/Drive Past Phone Book/Yellow Pages Mail Box/Flyer Korean Magazine/Newspaper Social Media/ Facebook Another Patient
Would you like more information about: *

Teeth Whitening Straightening Teeth Replacing Missing Teeth Bad Breath (Halitosis) Other
Name of your last dentist
When was your last dental visit?
Reason for your visit today?
Emergency Contact Details
Emergency Contact's Name *
Emergency Contact's Number *
Emergency Contact's Relationship to you *
example: wife/ partner/Mother
Medical Questions
Medical Doctor's Name
Clinic Name
Doctor's Phone Number
Are you taking any medicine tablets, capsules or drugs? *

Yes No
If Yes, please provide full medication list below?
Are you aware of ANY allergies or adverse reactions that you have (eg Latex, anaesthetic) *

Yes No
If Yes, please list below?
Have you been a patient in hospital during the past two years? *

Yes No
If Yes, please provide details below?
Are you receiving any medical treatment at the present time? *

Yes No
If Yes, please provide details below?
Have you had any prosthetic surgery (eg heart valve, hip replacement etc) *

Yes No
If Yes, please list the type of surgery AND year you underwent the surgery:
Women: Are you pregnant? *

Yes No Maybe
If Yes, please list how many weeks/months?
Do you smoke? *

Yes No
If Yes, how many cigarettes per day?
Have you ever had, or been treated for any of the following conditions. Please tick "yes" or "no"
Heart trouble? *

Yes No
High Blood Pressure? *

Yes No
Blood Disorders? *

Yes No
Anaemia? *

Yes No
Rheumatic Fever? *

Yes No
Asthma? *

Yes No
Bronchitis? *

Yes No
Gastric Reflux? *

Yes No
Stomach Ulcer? *

Yes No
Stroke? *

Yes No
Sinusitis? *

Yes No
Allergies? *

Yes No
Diabetes? *

Yes No
Hepatitis? *

Yes No
Arthritis? *

Yes No
Epilepsy? *

Yes No
Fainting or Dizziness? *

Yes No
Latex Sensitivity? *

Yes No
Epilepsy? *

Yes No
Do you have or are you at risk contracting any of the below:
Hepatitis B *

Yes No
Hepatitis C *

Yes No
HIV *

Yes No
Although rare, accidental injury to staff can occur during handling of used instruments. If this happens during the course of your treatment, our practice requires both patient and staff member to undertake blood tests. Do you agree to a confidential blood test? *

Yes No
AGREEMENT

Our Commitment to you: At all times we will provide you the very best dental care available in a modern, friendly environment. As a patient at Bays Dental, your well-being is our first priority. Your Commitment: I, the undersigned, agree to be responsible for payment of all services rendered on my behalf or on behalf of my dependents. I understand that payment is due at the time of treatment, unless other arrangements have been finalised. A 15% fee may be added to outstanding amounts. If required for debt collection, I understand that any costs incurred while debt collecting will be on-charged to me and that a check of my credit history may be made, and/or my details may be passed to a third party. I understand that by making appointments with Bays Dental, I am agreeing to attend the appointments or to give a minimum of 24 hours’ notice of cancellation of appointments. If I fail to attend an appointment, a ‘no show’ fee of $50 per half hour of the appointment may be charged.
Electronic Signature: Patient/Parent/Guardian *
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