Medical History Form

The information you provide is strictly confidential. The details of your medical history are relevant and important to us as this will enable us to provide you with the best dental care possible. 這張表格是密件。了解您的病史對我們來說非常重要，有助於我們為您提供最佳服務。

Title 稱號 (e.g., Miss/Mrs/Mr/Mx):

Last Name姓:

First Name(s)本名:

Preferred Name:

Date of birth生日:
日 / 月/ 西元年

Gender性別:
Male男 Female女 Other其他

Address地址:

Suburb區域:

Post Code郵編:

Home Phone電話號碼 (家)::

Mobile手機:

Email電郵:

Occupation職業:

Preferred method of contact(最佳聯絡方式): Phone電話 SMS短信 Email電郵

HOW DID YOU FIND OUT ABOUT US您通過哪種方式認識我們:

Emergency Contact Name緊急聯絡人:

Relationship關係:

Phone電話:

General Practitioner家醫名稱:

Phone電話:

Please list all the medication you are taking at present or have had in the past 6 months請提供您六個月以內吃過的藥:

Has your doctor advised you to take ANTIBIOTIC COVER before dental treatment?

您接受口腔治療前需要抗生素嗎?

Yes需要 No不需要

Please indicate if you have or have ever had any of the following conditions病歷:

What can we do to make your visit here more pleasant我們能如何讓您的治療過程更舒適呢?

Are you in a Health Fund with dental cover您有牙科保險嗎? Yes有 No沒有 If yes, please name the Health Fund*保險公司

Do you have a Medicare Card您有Medicare卡嗎? #

Ref:

Exp到期日:

We appreciate your help in keeping our schedule running efficiently. If you are unable to attend an appointment, please notify us 48 hours in advance, otherwise a fee of $50 may be charged.感謝您配合預約時間。如想改預約時間，請48小時前通知，臨時通知需收$50費。

Your signature簽名: (please click the box below to sign your signature)

(如18歲以下請家長或監護人簽名)

Date 日期 / /

Medical History Form Chinese(中文)