Medical History Form

We look forward to welcoming you to our Practice.

Please either complete this form online or download, print and complete our Medical History Form and bring it along to your first appointment. Alternatively, you may book with us over the phone and arrive 5 minutes prior to your appointment to fill out a form.


Personal Details

Medical History

Other Information

Consent for Treatment

I hereby authorise the dentist or designated team to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis

Upon such diagnosis, I authorize the dentist to perform all recommended treatment mutually agreed to by me and to employ such assistance as required to provide proper care

I agree to the use of anaesthetics’, sedatives and other medication as necessary. I fully understand that using anaesthetics agents embodies certain risks. I understand I can ask for complete recital of any possible complications.

I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made.

I authorise that this data may be reviewed by team members of the dental practice.

The Canberra Dental Surgery in Belconnen

Canberra Dental Care