Patient Health History Form

Patient Health History Form

Medical history form for a Dental Surgery Create a HIPAA Compliant Patient Health History Form today. Form Preview
Patient Health History Form Template | JotForm
  • Health History Form

    So we can ensure that we can provide you with the best possible care,

    you must answer all questions.

  • Your Medical History

  • Your Dental History

  • Terms & Conditions

  • Consent for Treatment:

    1. I hereby authorise the dentist or designated staff to take x-rays, study models, photographs and other diagnotic aids deemed appropriate by the dentist to make a thorough diagnosis as mutually agree upon by me. 
    2. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide the appropriate care.
    3. I agree to the use of anaestheics, sedatives and other medication as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
    4. I agree to be responsible for payment of all services rendered on my behalf and/or on behalf of my dependants. I understand that payment is due at anytime of service unless other arrangements have been made.

    Payment for Treatment:

    We expect and appreciate payment at the time of treatment. We accept Eftpos, Visa, Mastercard, American Express, personal cheque and cash.

    We also can process your private health fund claim at the time of your appointment but need your card at every visit. 

    Cancellation Policy:

    We have a 48 hour (2 business day) cancellation policy to allow us ample time to offer your appointment to another patient in need of it. A fee may be charged for missed appointments or failure to reschedule before the 48 hour time limit. 

    I understand the consent for treatment, the payment and cancellation policies as stated above. 

    By my electronic signature below, I agree to the terms and conditions.

  • Clear
  • Part of our patient identifiers for the National Standards one of the patient identifiers is to upload a photo of each patient into our database.

    Would you mind uploading a photo of yourself or taking a photo of yourself on your phone for your patient file. 

  • Should be Empty: