Updated Medical History Form Please enable JavaScript in your browser to complete this form.To provide you or your child with the most appropriate care, we need to ensure the information we have is current. Please fill in the details below Legal name as per medicare card *Preferred name *Preferred pronouns: He/She/TheyCurrent address *Phone number *Has there been a change in responsible party information? *YesNoIf yes, please provide details. NameEmailAddressPhonePoint of contact for discussion of clinical issues for minors: Father/Mother/OtherContact NameContact NumberAdd additional responsible party for shared accountsMedical Has there been an update of a medical diagnosis?Are there any medical concerns under current investigation?Is the patient currently taking any new or updated medications?YesNoIf selected Yes please list all current medicationsDoes the patient have any sensory needs or sensitivities that we should be aware of? Please specify any specific accommodations or consideration related to sensory processing.Does the patient suffer from any mental health conditions?YesNoAdditional CommentsWhen was the patients last dental check up?Within 6 monthsOver 6 months agoOver 12 months agoPlease provide the name of the dental practice that patient attendsPlease provide patients Dentist nameI consent to receive txt appt reminders and txt correspondence from the practice *I consentSubmit
