Medical and Dental History Form – Paediatric Dental Group

Patient (your child's) Details
Surname*
Given Names*
Preferred Name*
Date of Birth*
DD slash MM slash YYYY
Weight*
Gender*
- Male
- Female
Full Home Address*
Suburb*
State*
Country*
Postcode*
Medicare Number*
Reference*
Expiry Date*
Private Health Fund*
Membership Number*
Type of Cover (eg. Hospital):*

Primary parent/guardian details
- This person will be our point of contact.
- This person will be responsible for payment of fees.
- Invoice will be issued in this name.
Name*
Prefix First Last
Relationship, if other, please specify*
- Father
- Mother
- Legal Guardian
Full Home Address*
Suburb*
State*
Country*
Postcode*
Phone (Home)
(Mobile)*
(Work)
Email*
Occupation*

Other parent/guardian details
Name*
Prefix First Last
Relationship, if other, please specify*
- Father
- Mother
- Legal Guardian
Full Home Address*
Suburb*
State*
Country*
Postcode*
Phone (Home)
(Mobile)*
(Work)
Email*
Occupation*

Health decisions for your child
Are there any custody issues, which may affect your child's treatment and/or payment of accounts? If yes, please specify details*
- No
- Yes
Details of custody issues:*
Who has legal responsibility for health decisions about your child?*
- Either Parent
- Mother Only
- Father Only
- Must be both parents
- Child Safety

How did you find out about us?
How did you find out about us?*
Please provide details*

Your child's dental history
Name of your child's general dentist*
Address of your child's general dentist*
Is your child attending another dental specialist?*
- Yes
- No
Name*
Please list any concerns you have regarding your child's teeth or mouth*
Please provide details about any previous injury to your child’s mouth or teeth*
How frequently are your child's teeth brushed?*
Who does this?*
- Child
- Parent
What type of toothpaste is most commonly used?*

Pregnancy, birth and early childhood history
Any pregnancy complications?*
Gestational age*
- Full term
Birth Weight*
Any complications during labour or during/after delivery?*
Medical problems during 0-3 years (including chickenpox, respiratory conditions, ear infections, UTI)*

Animal Assisted Therapy consent

Your specialist maybe working with the assistance of a professionally trained and assessed therapy dog, Comet (labradoodle). We provide this as an additional service; we do not charge an additional fee.

While Comet is well trained and socialised, there are always risks with working with animals. These included the risk of allergies, illnesses and personal injury.

I consent to the presence of a Therapy Dog:
- I acknowledge that my child and myself have no known illness or allergy that would prevent me from interacting with and handling the Therapy Dog.
- I understand that Comet undergoes routine vet checks to maintain his health, however there are some illnesses that can pass between humans and dogs.
- I understand that Therapy Dogs are socialised, trained and assessed to work with people, however I acknowledge the risks of working with animals, including the risk of injury.
- I understand that following the specialists instruction on interacting with Comet at all times is crucial to enjoying a safe interaction.
- I acknowledge that my child and myself have no known pre-existing dog phobias or fears.
*
- Yes, I agree to all of the above and wish to have Comet the Therapy Dog present for our consultation if available
- No, I don’t agree to all of the above and do not wish to have Comet the Therapy Dog present at our consultation
Please note: It may not be safe for people whom are immune-suppressed to work with therapy animals. Please discuss this with your doctor.
Consent/Privacy/Release Information

In accordance with the Privacy Act (1988), all information collected by the Paediatric Dental Group is treated as confidential. To protect your privacy and that of your child, the Paediatric Dental Group operates in accordance with this Act.

We may use the information provided in the following ways:
- Disclosure to others involved in your child’s health care, including other health practitioners and hospital. This may occur through referral to other health practitioners
- Disclosure to a medical defence organisation if a medico-legal matter arises.
- Clinical Teaching.
- Sending SMS appointment reminders via mobile phone using the numbers provided by you.
- Leaving voicemails identifying the caller, using the numbers provided by you.
- Sending correspondence via email using the email addresses provided by you.
- Administrative purposes in running our practice including debt management agencies if required.
- Utilisation of photographs and other images including xrays for clinical teaching and promotion.
Parent/Guardian Consent*
- I have read the information above and understand the reason why my child’s information must be collected. I am also aware that this practice has a privacy policy on handling patient information. I understand that I not am obliged to provide information requested of me, but that my failure to do so may compromise the quality of the dental / health care and treatment given to my child. I am aware of my rights to access information collected about my child, except in some circumstances where access might be legitimately withheld. I understand I will be given an explanation in these circumstances. I understand that if my information is to be used for any other purpose other than set out above further consent will be obtained.
Use of clinical findings, photographs, x-ray images and demographic data for research, including sharing of information to collaborate with other research institutions. Your child’s personal details and identity will not be shared.*
Parent/Guardian consent*
- I have authority to consent on behalf of my child. I consent to examination, x-rays, treatment, collection of clinical records (including clinical photographs). I consent to the handling of my child’s information by this practice for the purposes set out above.
Please confirm that you have read and understood our Privacy Policy.*
- Yes, I have read and understand the Paediatric Dental Group Privacy Policy and I have read and understand the Privacy / Release Information.
Parent/Guardian Name*
Enter Full Name as Signature*
Date*
DD dash MM dash YYYY
Name
This field is for validation purposes and should be left unchanged.

Patient (your child's) Details

Primary parent/guardian details

Other parent/guardian details

Health decisions for your child

How did you find out about us?

Your child's dental history

Pregnancy, birth and early childhood history

Your child's medical history

Animal Assisted Therapy consent

Consent/Privacy/Release Information