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Client Consent Form (Adult)

Please fill out your details the best you can and submit the form below to assist us providing dental services to you.

Contact Information

First name

Last name

Date of Birth

Email

Phone

Street Address

Street Address Line 2

City

State

Postcode

Country

Health Information

Are you recieving any medical treatment at present?

No

Yes

Details (if yes)

Have you been hospitalised in the last 12 months?

No

Yes

Details (if yes)

Do you have a medical condition, illness, or injury?

No

Yes

Details (if yes)

Medical conditions - please select if you have ever had any of the following:

Anaemia

Asthma/ bronchitis/ lung conditions

Diabetes

Epilepsy

Excessive bleeding/ taking blood thinners

Nervous condition

Kidney disease

High or low blood pressure

Stroke

Heart complaint/ murmur

Heart valce disorder/ cardiac pacemaker

Osteoporosis/ bone disease

Stomach or digestive condition

Hepatitis or other liver disease

Cancer/ cancer treatment

Radiation therapy/ chemotherapy

Rheumatic Fever

Thyroid disease

Other

Any other conditions (ADHD, Autism, Sensory Concerns, Dental Anxiety)

Do you have any ALLERGIES (e.g. latex, milk protein, strawberries etc):

Are you taking any medication?

Do you have NDIS Funding? *

Yes

No

If yes are you?

NDIS Plan Managed

NDIS Self Managed

Do you have private health insurance?

What are your main concerns with your oral health?

What is your availability for appointments?

I declare that the information I’ve provided is accurate & complete

Thanks for submitting, our team will be in touch soon!

Building your oral health capacity at home

Email: admin@oralhealthhome.com

Dr Carol Tran | 0415 268 107

Leigh Harrison-Barry | 0415 042 766

We acknowledge the traditional Custodians of the land on which we operate, and pay our respects to their elders past, present and emerging. We respect human rights and preople of diverse genders and sexual orientation are welcomed and supported.

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