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(07) 4051 4580
Ground Floor "Accent on McLeod"
93-95 McLeod St
Cairns
QLD
4870
Home
Our Treatments
Preventive
Lip and Tongue Tie
Tongue and Lip Tie Guide
Dental Hygiene
Dental Hygiene Products
Amalgam Replacement
Children’s Dentistry – CDBS
Mouthguards
Air Abrasion
Laser Dentistry
Dysfunctional Breathing
Fluoride Treatment
Restorative
Crowns
Bridges
Dental Implants
Over Dentures
Dentures
Inlays and Onlays
Root Canal
Full Mouth Reconstruction
Orofacial Pain
TMJ Pain
Occlusal Splint Therapy
Occlusal Therapy & Migraine Treatment
Therapeutic Injectables
Neuropathic Pain
Medical
Oral Cancer Screening
Dry Mouth – Xerostomia
Bad Breath – Halitosis
Snoring & Sleep Apnoea
Investigation of Obstructive Sleep Apnoea
Nose score in snoring & OSA Assessment
Oventus O2Vent Optima
Myofunctional Therapy in OSA for Patients Handout
Tongue Exercises
Cosmetic
Porcelain Veneers
Teeth Whitening
Aesthetic Composite Bonding
Tooth Contouring
Gum Lifts
Digital Smile Design
Orthodontics
ClearCorrect
About Us
Our Team
Dr Bob Gibbins, BDSC (HONS) QLD
Patient Referrals
Finance Options
Smile Right
Patient Centre
Smile Gallery
Medical History Form
Injectables History Form
Patient Appreciation Program
Media Centre
Contact Us
Our comprehensive range
Achieve and maintain a healthy and beautiful smile
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Medical History Form
Medical History Form
Name
*
First
Last
Date
DD slash MM slash YYYY
Postal Address / P.O Box
*
Street Address
Address Line 2
City
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
State
Post Code
Home Phone
*
Mobile Phone
*
Work Phone
*
Email Address
*
Occupation
Whom may we thank for referring you to our practice?
How did you find us?
*
Our website
Friend
Doctor
Television advertising
Business card
White pages
Yellow pages
Radio advertising
PDC directory
Newspaper
Directory
Other
Please list the main reasons for seeking care today:
*
The name of your private health fund:
Emergency contact:
*
Relation to emergency contact:
Husband
Wife
Partner
Mother
Father
Other
Emergency contact phone number:
Name of your doctor:
Doctor's Address:
Doctor's Phone:
Is another family member a patient at our office?
Yes
No
In order to render dental treatment of a high standard, it is necessary to have the following information (which will be handled confidentially). Please help us protect your health and well being.
Have you had any of the following medical conditions?
Heart Problems
Blood Pressure
Artificial joints
Rheumatic Fever
Circulatory problems
Radiation treatment
Excessive bleeding
Excessive bruising
Stomach Ulcers
Sinus trouble
Tumour history
Allergies to anaesthetics
Allergies to penicillin
Allergies to latex
Anaemia or other blood disorders
Diabetes
Asthma
Osteoporosis
Epilepsy
Liver or Kidney Problems
HIV, Hepatitis B or C
Dental History
Have you had any of the following?
Jaw click or hurt?
Feel you grind your teeth?
Had orthodontic treatment?
Do you wear a night guard?
Had gum disease?
Had your bite adjusted?
Bite your lips or cheeks often?
Do you smoke?
Have occasional bad breath?
Gums bleed when you brush your teeth
Experience sensitivity with hot/cold?
Food gets jammed between your teeth?
Floss ever catch between your teeth?
Teeth ever hurt when you bite hard?
Do you snore?
Dental Other:
Other Details
Do you play contact sports:
Yes
No
Would you like whiter teeth?
Yes
If you had a magic wand how would your smile improve?
How long since your last dental appointment?
How often do you have dental examinations?
Previous dental x-rays were taken:
Less than a year ago
Longer than a year ago
Your Oral Health Examination will be very thorough, and you can expect a manual examination of your jaw muscles, jaw joints (TMJs), lymph nodes, below the jaw and in the neck checking for Oral Cancer and other orofacial pathologies.We will likely suggest an initial set of X-Rays if you have not already had them done in the previous 6 months, and possibly other tests all of which will be described prior to doing any.
Payment Plans are available to approved applicants, but these will need to be established before any treatment is done if you wish to use such a Plan. Please ask us for details. Any delay in payment will incur compounding interest based on 1.75% per calendar month and an account maintenance fee of $15. All costs of debt collection will be passed on to you.Appointment confirmation and failure to attend appointments:Please acknowledge your preference to receive confirmation SMS or Email to remind you of upcoming appointments. YES NOShould you choose Not to receive confirmation, you are responsible for keeping your appointments.If you choose not to receive confirmations, and fail to attend your appointment, a fee may result.Should you wish to receive confirmations, we will make attempts to contact you using your preferred phone number and/or your given email address.Please note, if our attempts to contact you on your given mobile phone or email address do not get answered with a confirmation at the latest one full working day (Monday to Thursday), your appointment will automatically be cancelled.Cancellation of Appointments: Should you wish to cancel or shorten any appointment we require at least one full working days’ notice. A weekend cancellation for a Monday appointment is not adequate notice. Failure to give adequate notice may incur a cancellation fee based on $90 per 30-minute plus a further $90 for each additional 30 minutes or part thereof of appointment time. This is not refundable.If leaving a message over the weekend or overnight does not give us at least one full working day notice, your appointment will be automatically cancelled.Failure to attend: Any patient who fails to attend any appointment may be charged a cancellation fee which is not refundable based on the same fees as with Cancellations without adequate notice above. This is not refundable.To make further appointments, we reserve the right to charge a booking fee, which needs to be paid fully at the time of booking the appointment.Repeated failure to attend appointments may result in you not being seen again except under possible emergencies.
I, (please print name)
Or Parent/Guardian (Please tick) of name
Parent
Guardian
Consent
By ticking this box, I give consent to the dentist to perform all procedures deemed necessary from your oral health examination. I understand any treatment to be done will be discussed in detail prior to any treatment with you including fees and alternatives. You will be given a treatment plan for your subsequent visits for which we will have you sign with informed consent at each visit.
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Our Treatments
Preventive
Restorative
Orofacial Pain
Medical
Cosmetic
Orthodontics
Make an Enquiry
Contact Details
Phone
(07) 4051 4580
Fax
(07) 4031 5226
Email
info@futuredental.com.au
Address
Ground Floor "Accent on McLeod"
93-95 McLeod St
Cairns
QLD
4870
Hours
Monday
8:00am - 5:00pm
Tuesday
8:00am - 5:00pm
Wednesday
8:00am - 5:00pm
Thursday
8:00am - 5:00pm
Home
Our Treatments
Preventive
Lip and Tongue Tie
Tongue and Lip Tie Guide
Dental Hygiene
Dental Hygiene Products
Amalgam Replacement
Children’s Dentistry – CDBS
Mouthguards
Air Abrasion
Laser Dentistry
Dysfunctional Breathing
Fluoride Treatment
Restorative
Crowns
Bridges
Dental Implants
Over Dentures
Dentures
Inlays and Onlays
Root Canal
Full Mouth Reconstruction
Orofacial Pain
TMJ Pain
Occlusal Splint Therapy
Occlusal Therapy & Migraine Treatment
Therapeutic Injectables
Neuropathic Pain
Medical
Oral Cancer Screening
Dry Mouth – Xerostomia
Bad Breath – Halitosis
Snoring & Sleep Apnoea
Investigation of Obstructive Sleep Apnoea
Nose score in snoring & OSA Assessment
Oventus O2Vent Optima
Myofunctional Therapy in OSA for Patients Handout
Tongue Exercises
Cosmetic
Porcelain Veneers
Teeth Whitening
Aesthetic Composite Bonding
Tooth Contouring
Gum Lifts
Digital Smile Design
Orthodontics
ClearCorrect
About Us
Our Team
Dr Bob Gibbins, BDSC (HONS) QLD
Patient Referrals
Finance Options
Smile Right
Patient Centre
Smile Gallery
Medical History Form
Injectables History Form
Patient Appreciation Program
Media Centre
Contact Us
It is a requirement for all persons (including accompanying person/s) who enter Future Dental to scan the QR code and fill in a COVID screen.
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Did you know you’re at more risk of cracking teeth with those old silver “Amalgam” fillings? Talk to us about amalgam replacement!
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The wait is over!You don’t have to wait weeks for your crowns, talk to us about E4D crowns and One Visit Crowns
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Learn More
Did you know? Untreated Obstructive Sleep Apnoea can increase risk of serious health problems like heart attack and stroke
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FACT - Dry mouth leaves you at risk of decay, and we can help with your dry mouth.
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Lip and Tongue Tie can affect your baby’s growth and development, come and see Dr Bob about how we can help.
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Did you know regular efficient flossing keeps not just your teeth, but your gums healthy too? Talk to us about Dental Hygiene
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FACT – sometimes migraines are caused by grinding your teeth! Talk to us about Occlusal Therapy and Migraine Treatment and Therapeutic Injectables
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Learn More
Teeth Whitening has never been so easy! Ask us why.
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Straightening your teeth doesn’t have to mean braces, talk to us about ClearCorrect
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Learn More
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