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07 3448 9279info@mapledentalcare.auMonday - Friday 8:30-17:00Closed Saturday & Sunday67 Capestone BlvdCapestone Village

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Booking Confirmed

Thank you for booking with Maple Dental Care

If you are a new patient or if any of your details may have changed since your last visit. Please complete the medical history form below.

We look forward to seeing you at your appointment. Please call us if you have any questions or need to make any changes on 07 3448 9279

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– Step 1 of 7

PATIENT DETAILS

Title *

Patient Name *

First

Last

Date of Birth *

Email *

Mobile Number *

Work Phone

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Occupation

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name *

First

Last

Contact Number *

Relation to Patient

Relation *

Private Health Information

Do you have Private Health Cover? *

Yes
No

Health Fund Selection *

Member Number *

Series Number *

Child Dental Benefits Scheme (CDBS)

The Child Dental benefits Scheme (CDBS) is a government funded scheme to allow children to access free dental care subsidies. Children under the age of 18 may be eligible. Please enter their details below and we will check if they qualify.

Would you like us to check patient eligibility? (Must be under 18 y/o) *

Yes
No

Full Name of Patient *

Medicare Card Number *

Number Next to Patients Name *

Medical Information

Any Major Surgeries / Operations / Illnesses in the past 2 years?

Yes
No

Surgery / Illness Information *

Date of Surgery *

Are you currently taking any medication (Prescribed or over the counter)? *

Yes
No

Please List All Medications (Both Prescribed & Over the Counter) *

Do you have any Abnormal Reactions to Local or General Anaesthesia? *

Yes
No

Please provide additional information *

Do you Smoke? *

Yes
No

How Many Per Day?

Selected Value: 0

Are You Pregnant? *

Yes
No
Unsure

Pre-existing Medical Conditions (Please Select All That Apply) *

None (of the Below)
Rheumatic Fever
Asthma
Heart Valve Disorder
Radiation Therapy
Excessive Bleeding
Nervous Condition
Hear Murmur
High Blood Pressure
Low Blood Pressure
Cardiac Pacemaker
Steroid Therapy
Epilepsy
Diabetes
Stroke
Kidney Disease
Heart Complaint
Tuberculosis
Prosthetic Implant
Stomach or Digestive Condition
Hepatitis or other Liver Disease
Immune Deficiency
Bronchitis, Emphysema or Other Lung Disease
Anemia, Leukemia or Other Blood Disease
Transplanted Organ or Marrow
Other

Medical Conditions / Additional Information *

Have you had an Organ Transplant? *

Yes
No

Organ(s) Transplanted *

Heart
Lung
Kidney
Liver
Other

Surgeon / Specialist Contact Information *

Have you ever had any Heart Operations / Surgeries? *

Yes
No

Surgeon / Specialist Contact Information

Do you have any Allergies to Drugs or Medications? *

Yes
No

Please list ALL Drugs & Medications you are allergic to: *

Do you have any allergies (including Latex): *

Yes
No

Please list any known allergies (including Latex): *

Please describe any dental problem(s) you may be experiencing *

FINAL STEPS

How Did You Hear About Us? *

Internet/Search Engine
Friend Referal
Social Media
Referral
Third-Party Review
Other

If other, please specify *

Checkboxes *

Accept

In order to provide you with the highest standard of dental care, this practice is required to collect personal information from you. This information covers basic details such as your name, address and telephone number but it is also necessary for the dentist to obtain from you details regarding your general health and past medical and surgical events. Without this general health picture, the treating dentist is unable to plan your care properly. Naturally, some of this information is of a personal nature and some of it might be regarded as ‘sensitive’ and not the sort of information that you would wish to be unnecessarily disclosed to others.

We value the need to safeguard this information and, in accordance with the principles laid down in privacy legislation and the guidelines issued by the Australian Dental Association, we would like to assure you that:

This information will only be used by the treating dentist in order to deliver your care to the highest standards.

It will not be disclosed to those not associated with your treatment without your consent except as provided under the legislation and where we consider you would have a reasonable expectation of us to provide such information.

You may seek access to the information held about you and we will provide this access without undue delay. This access might be by inspection of your dental records at the time of appointment or by special access or copying of information at other times.

There will be no charge made for requesting this information but there may be fees levied just to cover the costs associated with the processing of this request or the copying of information.

We will take reasonable steps to ensure at all times that the details we keep about you are accurate, complete and up to date.

We will take reasonable steps to protect this information from misuse or loss and from unauthorized access, modification or disclosure.

Our staff are trained to respect these principles at all times.

PAYMENT POLICY

I verify that all details I have provided in the medical history form on the reverse is true and accurate. I confirm that by accepting a an appointment and / or treatment there is likely a to a related fee.

I indemnify Maple Dental Group Pty Ltd from and against all costs and disbursement incurred in recovering overdue invoices (including but not limited to legal costs, collection agency costs, internal administration costs and bank dishonour fees). I understand that interest on overdue invoices shall accrue daily from the date of unpaid treatment to the date of payment at a rate of four per cent (4.0%) per calendar month.

Name of Patient or Guardian *

First

Last

Todays Date *

Signature *

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Maple Dental Care welcomes all general and emergency patients. Call 07 3448 9279 to book in today!

CONTACT NUMBER

07 3448 9279

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