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Medical FormMitch Ellems2026-07-17T11:21:46+10:00

Patient History Form

Please complete the secure form below including all required information.

Once you complete the form the information will be sent securely to the practice ahead of your appointment.

"*" indicates required fields

1Personal Details
2Medical History
3Dental History
4Contact Preferences
5Privacy & Consent

Personal details

Tick this if post address is different
Preferred Contact Number*
DD slash MM slash YYYY

Medical history

Have you ever had or are suffering from PLEASE TICK
1 Allergy to anaesthetics*

2 Allergy to medications*

3 Any other Allergies*

4 Heart Complaints*

5 Rheumatic Fever*

6 Pacemaker or defibrillator*

7 Have you had antibiotics for dental treatment before*

8 Excessive bleeding*

9 Blood Pressure (high or low)*

10 Diabetes*

11 Epilepsy*

12 Tuberculosis*

13 Asthma or respiratory condition*

14 Gastro intestinal disorders*

15 Stroke*

16 Hepatitis A B or C*

17 HIV*

18 Bone disorders including Osteoporosis*

19 Are you pregnant/breastfeeding*

20 Cancer*

21 Radiation or chemotherapy*

22 Are you Smoking or Vaping*

23 Any nervous or mental health conditions*

24 Any previous medical surgery*

25 Any other medical condition*
26 Medications including:
Medication / Injections for bones*
More Details
Medication
Dose
How Often
 

Medications to thin the blood*
More Details
Medication
Dose
How Often
 

Steroids*
More Details
Medication
Dose
How Often
 

Any other medications*
More Details
Medication
Dose
How Often
 
30 Are you seeing any other medical specialists*

Dental history

DD slash MM slash YYYY
How often do you clean your teeth*
Do your gums bleed when you clean your teeth
Do you normally see a hygienist
Are you happy with the appearance of your teeth
Are you happy with the colour of your teeth
Do you have Private Health Insurance*
HOW DID YOU FIND US*
Do you have preferred days and times

Privacy policy & consent

In order to provide you with the highest standard of dental care, our 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 us to obtain from you details regarding your general health and past medical or surgical events. Without this general information we would be hindered in giving you the correct treatment.

A full copy of the way we maintain your privacy is available on our website at www.cjdentistry.com.au/privacy or is available at the reception desk.

Please read and sign below if you give your consent to the following:
I consent to the use of my dental records (eg. dental x-rays, photographs, plaster models etc.) for purposes of consultations, consultations with my orthodontic/ doctor/health professionals, for educational and research purposes, publication in professional journals, or use in professional collateral materials. I do not consent to the use of my specific name, address, or other identifying information without further written consent.

PLEASE BE AWARE FULL PAYMENT IS REQUIRED AT THE TIME OF APPOINTMENT
Clear Signature
DD slash MM slash YYYY

Currey & Jorgensen Dentistry gives you a reason to keep smiling and to feel confident about it!

Contact details

  • 1/130 Alexandra Parade
    Alexandra Headland QLD 4572
  • (07) 5479 5522
  • reception@cjdentistry.com.au

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About Our Practice

Our dental practice is made up of a group of hand-picked dentists, hygienists and auxiliary staff dedicated to providing you with the highest quality dental and oral care.

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Contact Info

1/128-130 Alexandra Parade, Alexandra Headland QLD 4572

Phone: (07) 5479 5522

Email: reception@cjdentistry.com.au

Web: Currey & Jorgensen Dentistry