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Medical and Dental History Care For Smiles
Private and Confidential. Page 1 of 2.

Dr Rosemary Phillipos and her team welcome you to Care For Smiles. We assure you a caring and gentle
environment and our complete attention to make your visit comfortable and relaxing.
To assist in determining your treatment needs, please fill both sides of this form.
Contact Details
Surname . First name . Title (Mr, Mrs, Miss, Ms, Dr) .
Preferred name . Date of Birth . / . / .
Home address . Postcode .
Postal address (if different to above) . Postcode .
Telephone: Home . Mobile . Email .
Occupation . Work Phone .
Emergency contact . Relationship to patient . Telephone .
Care For Smiles bulk-bills treatments for holders of a valid Medicare Teen Dental Plan voucher or a valid DVA Gold
or White Card. Care For Smiles offers 10% discount (conditions apply) to holders of a valid Seniors or Carers card.
How would you pay for your treatment?  Cash
 EFTPOS / American Express / Mastercard / Visa  I have Health Insurance with Dental Cover: Health fund . Member No. . Seq . (HCF Health Fund members with Extras Cover are entitled to two free check-ups and cleans and more each year)  I am a War Veteran (DVA Gold or White Card) Is a third party, insurance company/employer responsible for this account  Yes Details . For patients under 16 only:
Person responsible for accounts . Relationship to patient . How did you hear about Care For Smiles? .
How would you like us to contact you?  Mobile  SMS  Email  Mail  Phone  Other .
Is there any Personal / Family situation that would make keeping your appointments difficult?  No  Yes
Dental Questionnaire
When was your last visit to a dentist? . Reason .
Have you made this appointment for a
Are you concerned about or experiencing any of the following? (Please tick those that apply)
 Existing crowns, bridges or dentures  Grinding or clenching of your teeth Does dental treatment make you nervous?  No
If dental treatment makes you nervous have you considered nitrous oxide (happy gas)?
Now, fill in Page 2 of this form.
Care For Smiles Dental Clinic, 1-3 Louisa Street, Coburg. Phone 03 9384 6155. Email
Medical and Dental History Care For Smiles
Private and Confidential. Page 2 of 2.

Please answer these questions fully or discuss with the dentist.
Medical Questionnaire
Medical practitioner: Name: . Suburb .
Past / Present medical conditions. (Please tick those that apply)
Are you receiving any medical treatment at present? Have you had any serious or long standing illness? Have you had Heart or Joint Replacement Surgery? Have you stopped taking any medication in the last week? Are you allergic to any medication or antibiotics? Had cosmetic or other surgery to mouth, jaw, lips or face?  Yes Have you ever had any of the following? (Please tick those that apply)
Are you on any of the following medications? (Please tick those that apply)
 Blood thinning (Aspirin / Warfarin / Plavix)  Cortisone (Prednisolone)  Thyroid (Thyroxin / Oroxin)  Vitamins or Herbal Supplements  Psychiatric (Anti-depressants / Lithium / Anti-anxiety / Sleeping tablets) Female patients: Are you pregnant?
How many cigarettes do you smoke per day? . Privacy Policy
Our Privacy Policy can be viewed on our website .
The information collected by our practice will be used for the purpose of providing treatment to you. Personal information will be used to address accounts to you, process payments and write to you about our services and any issues affecting your treatment.  We may disclose your health information to other health care professionals, or require it from them if it is necessary in the context of your treatment. In that event, disclosure of your personal details will be minimised wherever possible.  Your medical history, treatment records, x-rays and any other material relevant to your treatment will be kept here. You may inspect or request copies of our records of your treatment at any time. Fees may apply.  If any information we have about you is inaccurate, you may ask us to alter our records accordingly.  Your health information will be treated with the utmost confidentiality. Disclosure will not be made to any person not involved in either your treatment or the administration of this practice without your prior written consent. If you have any queries or concerns please do not hesitate to raise these concerns with our practice. Patient Signature
Care For Smiles Dental Clinic, 1-3 Louisa Street, Coburg. Phone 03 9384 6155. Email


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