Medical History Form

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Future Dental

Patient Information, Medical History & Informed Consent

Personal Information

Full Name(Required)

First Last

Preferred Name

What would you like to be called?

Date of Birth(Required)

Home Address

Street Address Address Line 2 City State Post Code

Home Phone

Mobile(Required)

Email Address(Required)

Work Phone

Best contact number during business hours(Required)

The number you will answer Mon–Wed, 8am–5pm

Emergency Contact

Emergency Contact Name(Required)

Relationship to Emergency Contact

Emergency Contact Phone(Required)

Your Doctor

Medical Doctor's Name

Medical Practice Name

Doctor's Phone Number

Health & Insurance

Health Fund Name

Do you have private dental insurance?

Yes

No

Interested in payment plan options?

Yes – please send me information

No thanks

Who is paying your dental fees?(Required)

How Did You Find Us?

How did you find Future Dental?

If 'Other' — please specify

Who can we thank for referring you?

Standby List

Would you like to be on our standby list for earlier appointments?

Yes – contact me if an earlier slot becomes available

No thanks

If a cancellation occurs we will contact you to offer an earlier time.

How much notice do you need?

e.g. 24 hours, 2 days

Best phone for standby contact

Appointment Reminders

Appointment reminder preference(Required)

I would like SMS and/or email reminders

I take full responsibility for keeping my appointments

If you choose reminders: your appointment will be automatically cancelled if we do not receive confirmation at least 24 hours before (Mon–Wed business hours).

Practice Policies — Please Read Carefully

Payment
Payment in full is required at the time of service. We do not issue accounts. After your first visit, treatment details and fees will be provided in writing for your signature.

Payment Plans
Payment plans are available to approved applicants and must be established before any treatment commences. Any delay in payment will incur interest at 1.75% per calendar month plus an account maintenance fee of $25. All debt collection costs will be passed on to you.

Cancellations — 24 Hours Notice Required
At least one full working day (24 hours) notice is required to cancel or shorten any appointment. Office hours: Monday to Wednesday, 8:00am to 5:00pm. A Thursday/Friday/weekend cancellation for a Monday appointment is not adequate notice. Inadequate notice may result in a cancellation fee of $90 per 30 minutes or part thereof. This fee is non-refundable.

Failure to Attend
Failure to attend without adequate notice may result in a cancellation fee ($90 per 30-minute block). We reserve the right to charge a pre-paid booking fee for future appointments. Repeated failures to attend may result in you not being seen again.

Long Appointments and Laboratory Work
Failure to attend or late cancellation for a signed long appointment may result in a charge for the full fee. Laboratory work is invoiced at the commencement appointment. Full payment or minimum 50% is required at the first appointment.

Treatment Consent
All treatment options will be discussed with you in detail before any work begins. Verbal consent given to the dentist is legally binding and payment is required at the end of that appointment. A signed treatment plan will be provided for each subsequent visit.

Dental Records and X-Rays
Dental records including X-rays are the legal property of the practice. To transfer records, that practice must forward a signed Records Release Form to us.

Child Dental Benefit Scheme (Medicare CDBS)
Certain services may not be covered or may have a gap fee and the annual limit may be reached. Any out-of-pocket expenses will be discussed before treatment. Once the CDBS limit is reached you are financially responsible for all further fees.

Declaration & Signature

I, (please print name)(Required)

If signing on behalf of a child, enter the parent or guardian's full name.

Or Parent / Guardian (Please tick)

Parent

Guardian

Monday	8:00am - 5:00pm
Tuesday	8:00am - 5:00pm
Wednesday	8:00am - 5:00pm
Thursday	8:00am - 5:00pm

Our comprehensive range

Future Dental Patient Medical History Form

Future Dental

Personal Information

Emergency Contact

Your Doctor

Health & Insurance

How Did You Find Us?

Lifestyle & Habits

Heart Conditions

Blood Conditions

Allergies

Clinical Warnings

Chest & Respiratory

Other Medical Conditions

Medications, Supplements & Remedies

Standby List

Appointment Reminders

Declaration & Signature

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