Name *

First Name

Last Name

Work phone

(###)

###

####

Home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please tick if you have Southern Cross dental insurance?

Our on-line access to Southern Cross will allow us to submit your claim on the same day as your treatment

YES

NO

Emergency contact name *

First Name

Last Name

Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?

YES

NO

HEART

Rheumatic Fever

Angina

Pacemaker fitted

Heart Murmur

Heart surgery

Thromosis

High/Low blood pressure

Stroke

Other heart conditions

BLOOD

Hepatitis A,B,C or D

Abnormal blood test

Transfusion service/refused blood

Anaemia

Sickle cell

Haemophilia

H.I.V./AIDS

Other blood conditions

ALLERGY

Penicillin allergy

Hayfever allergy

Anti tetanus serum allergy

Eczema allergy

Latex allergy

Medicines allergy

Plants allergy

Food allergy

Local anaesthetic allergy

General anaesthetic allergy

Aspirin allergy

Other allergy conditions

CHEST

Bronchitis

Cystic Fibrosis

Pleurisy

Emphysema

Pneumonia

Chest Surgery

Asthmatic

Tuberculosis

Other chest conditions

OTHER

Cancer/Radiotherapy

Artificial Joint

Bone or joint disease

Antibiotic cover required

Bruising or persistent bleeding

Currently under treatment

Cold Sores

Severe headaches/Migrains

Kidney disease

Fainting / blackouts

Past infectious disease

Depressive illness

Treatment requiring hospital

Hearing/Sight impaired

Warning card

Nervous problems

Epilepsy

Pregnant / possibly pregnant

Liver disease

Diabetes

Acid reflux or eating disorder

Do not recline

Steroids within 2 years

Hiatus Hernia

ACC Surcharge *

We will submit an invoice to ACC for required treatment, surcharge payment is required at time of treatment. Should your parent to be responsible for payment please provide their contact information below. We will contact them to confirm this arrangement.

Agree

Payor responsible

First Name

Last Name

Phone

(###)

###

####

CLICK HERE TO CONFIRM INFORMATION

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to determine the appropriate management of my treatment. If there is any change in my medical status, I will inform the dentist. I authorise the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges whether or not paid by insurance.

I CONFIRM