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Day	Hours
M	9:00 AM - 6:00 PM
T	9:00 AM - 6:00 PM
W	9:00 AM - 6:00 PM
T	9:00 AM - 6:00 PM
Every Second Saturday 9AM - 1PM

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Dentist Moonee Ponds | Innovative Dental

Dental Clinic in Moonee Ponds

2/140 Pascoe Vale Rd
Moonee Ponds, VIC 3039

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Home
Special Offers
About
- About Us
- Dental FAQ’s
Treatments
Patient Information
Blog
Contact

Medical History Form

Welcome to our Practice! please take your time to answer these questions as completely as possible. It will assist us greatly in our effort to provide the best dental treatment for you. All your answers will be treated in the strictest confidence.

Please Select^* :	Surname^*	First Name^*
Address^*		Postcode^*	Date of Birth^*
		Mobile^*
Email Address^*		Tel(Home)^*	Tel(Bus)^*
Emergency Contact/ Name and telephone^*
Name of Dental Insurance	Recommended by:	What is the purpose of your visit?

PLEASE TICK THE APPROPRIATE ANSWER

Do you feel very nervous about having dental treatment?	YESNO
Have you ever had a difficult tooth extraction?	YESNO
Have you ever stayed in hospital or had a operation?	YESNO
Are you allergic to any tablets or medicines?	YESNO
Do you smoke?	YESNO
Do you have an artificial hip, heart valve or other implant?	YESNO
Are you currently taking any medication?	YESNO
WOMEN
Are you pregnant?	YESNO
Are you currently taking the contraceptive pill?	YESNO

TICK ANY OF THE FOLLOWING THAT YOU HAVE HAD OR HAVE AT PRESENT

Heart ProblemsAsthmaDiabetesBlood Pressure

Chest problemsArthritisKidney/Liver diseaseRheumatic Fever

Fits or epilepsyThyroid ProblemsStrokeBleeding disorder

Do you have any disease, condition or problem not listed:

Are you happy with the appearance of your teeth?	YESNO
Who is your medical doctor?

PLEASE ADVISE US OF ANY CHANGE IN THE ABOVE INFORMATION. THANK YOU FOR YOUR HELP.

Terms & Conditions Apply

Innovative Dental

PROVIDER

Bupa

Medibank

TREATMENTS

General Dentistry
Cosmetic Dentistry
Dental Implants
Orthodontics

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FREE PARKING

We are close to transport and free street parking is available.

CONTACT INFO

Innovative Dental

Address: 2/140 Pascoe Vale Rd
Moonee Ponds VIC 3039

Phone: (03) 9346 8333

Email: info@innovativedental.com.au

Opening Hours:

Mon - Thu	9:00 AM - 6:00 PM
Every Second Saturday 9AM - 1PM

© 2020 Innovative Dental. All Rights Reserved.
* Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.
** Terms & Conditions Apply to all promotions.

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