Dickson Dental TLC 4/30-36 Woolley Street

Dr. Hsin-Lung FangDickson ACT 2602

TitleDr/Mr/Mrs/Ms/Miss/Other

Surname ______First Name ______Date of Birth ______

Home Address ______

Postal Address if different ______

Phone (Mob) ______(Home) ______(Work) ______

Health Fund for Dental Cover ______Membership No ______Patient ID ______

Medicare Card No ______Veteran’s Affairs Card No ______

Occupation ______

Emergency Contact ______Relationship to Patient ______Ph ______

Person responsible for account (must be completed if patient is under 18) or same as aboveYes/No

Full Name ______Relationship to Patient ______

Address ______

Phone (Mob) ______(Home) ______(Work) ______

If third part, insurance company/employer responsible for account ______

Medical Questionnaire – Private and Confidential

Please answer these questions fully or discuss them with the dentist, information about your medical history is for your dentist only.
Do you have any history of, or even suffered from the following? Please circle only those that apply.

Heart ProblemsHeart MurmurHeart SurgeryPacemaker

Rheumatic FeverKidney DiseaseLiver DiseaseChest Problems

HayfeverAsthmaDiabetesAnaemia

HepatitisBlood TransfusionEpilepsyHigh Blood Pressure

GiddinessThyroid DiseaseAllergiesOther


For Other and/or allergies (food/antibiotics) ______
Are you pregnantYesNo

Have you ever had a bad reaction to local anaestheticYesNo

Do you have a family doctorYes No

If yes, please give details ______

Are you currently taking any medication Yes No

How long since your last dental visit ______

How did you choose this practiceYellow PagesFamily/Friend ReferralOther?

I agree that the above is a true and accurate record. I understand that his dental practice requires payment on the day of treatment. Any expenses, costs or disbursements incurred b Dickson Dental TLC in recovering any outstanding monies including debt collection fees and solicitor costs shall be paid by the responsible part above. I further acknowledge that failure to attend any appointment without notice may result in a deposit requirement prior to future appointments being scheduled. Also a broken appointment fee will be charged. I also understand it is the right of Dickson Dental TLC to refuse treatment.

Please Note: The medical history form will be electronically copied to your clinical file and the original will be destroyed, by signing this document you agree to this process. This form is a guide only and you should discuss and relevant matters with your dentist.

Signature ______Date ______

  • Please let us know if you wish to transfer your medical records from another dentist