Medical & Dental History

Medical & Dental History Form

We Respect Your Privacy

It is important for us to know details of your medical and dental history so that your treatment plan can be tailored to your personal needs. We assure you this information will be held in strict confidence and not disclosed to any other persons or parties, unless you give permission to do so.

  • This field is for validation purposes and should be left unchanged.
  • DD slash MM slash YYYY
  • Please indicate below if you have, or have ever had, any of the following:
  • For your comfort: Many people are still nervous about coming to the dentist. Whilst the improvements in techniques and anaesthetics have helped most people, you may still be apprehensive and wish us to take extra measures for your comfort. Please indicate your present level of apprehension (0= completely at ease, 10= petrified)
    Please enter a number from 0 to 10.
  • DD slash MM slash YYYY
  • Are you aware of any of the following oral symptoms?
  • Dr Hoffman and staff do expect and appreciate you keeping your agreed appointment. If breaking your appointment becomes unavoidable, the more notice you provide the better, as this enables us to reschedule other patients and avoid highly trained staff and equipment sitting idle. Consequently, we require one week notice, or 48 hours as an absolute minimum. If we receive less than 48 hours notice, a cancellation fee of $150.00 will apply.
  • I acknowledge I have filled in this form to the best of my knowledge and ability, as honestly and correctly as possible.