Go Dental Wagga | Dentist in Wagga Wagga

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Preferred Name

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Address(Required)

Street Address City State Postcode Country

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Home

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Private Health Fund Name

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Does your health fund cover dental?

Yes

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White

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Expiry

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ALL FEES MUST BE PAID IN FULL ON DAY OF TREATMENT

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*This must be different to the main contact number.

Medical Practice / GP

Phone Number

How did you hear about our practice?

Please see the below medical conditions, then follow the next question.


Pregnant	Smoking	Allergies
Any Surgery within the last 6-12	Blood Pressure (High / Low)	Blood Thinners
Pacemaker / Heart Surgery	Type 1 / Type 2 Diabetes	Epilepsy / Stroke
Asthma / Hay Fever / Sinus	Thyroid	Immune System Disorder
Mental Health / Depression / Anxiety	Autism / Behavioural Condition	HIV
Hepatitis A, B or C	Rheumatic Fever	Bleeding / Blood Disorders
Dizziness / Fainting	Gastric Disorder / Reflux	Cancer / Radiation / Chemotherapy
Liver / Kidney Disorder	Lung Disorder / Tuberculosis	Osteoperosis
Corticosteroids / Steroids	Bisphosphonates	Viagra (Yes, we need to know.)
Recreational Drug Use	Anything Not Mentioned

Please select any medical conditions you are / have experienced.

If you have ticked any of the boxes, or have any concerns please advise further details of your medical conditions, and any medications you are / have used.

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Medical History Form

ALL FEES MUST BE PAID IN FULL ON DAY OF TREATMENT

Contact

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