Dental Sleep Med Form

Medical History Form

Name(Required)
MM slash DD slash YYYY
Address(Required)
Doctor's Address
Is another family member a patient at our office?
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?

Dental History

Have you had any of the following?

Other Detials

Do you play contact sports:
Would you like whiter teeth
Previous dental x-rays were taken:
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 NO

Should 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.

Or Parent/Guardian (Please tick) of name
Consent