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171 Acland St, St Kilda VIC 3182
(03) 9534 8611
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GENERAL DENTISTRY
PERIODONTAL
CROWN & BRIDGE
ROOT CANAL
MINIMALLY INVASIVE (MI) DENTISTRY
COSMETIC DENTISTRY
TEETH WHITENING
VENEERS
STRAIGHTENING TEETH
DIGITAL SMILE DESIGN
TOOTHACHES
PAIN MANAGEMENT
EMERGENCY TREATMENT COSTS
OTHERS
WISDOM TEETH
DENTAL IMPLANTS
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Home
Our Services
GENERAL DENTISTRY
PERIODONTAL
CROWN & BRIDGE
ROOT CANAL
MINIMALLY INVASIVE (MI) DENTISTRY
COSMETIC DENTISTRY
TEETH WHITENING
VENEERS
STRAIGHTENING TEETH
DIGITAL SMILE DESIGN
TOOTHACHES
PAIN MANAGEMENT
EMERGENCY TREATMENT COSTS
OTHERS
WISDOM TEETH
DENTAL IMPLANTS
Reviews
Contact
About Us
Search
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Medical History Questionaire
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First name
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Date of Birth
Mobile Number
Email
Home address
2nd address
Postal address
Emergency contact name
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Relationship
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How did you hear about us:
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Do you suffer from any of the following?
High blood pressure
Heart ailment
Rheumatic fever
Asthma, chest or breathing problems
Tuberculosis
Stomach or bowel problems (eg ulcer)
Kidney disease
Diabetes
Depression (needing medication)
Excessive bleeding or blood disorder
Epilepsy
Hepatitis
AIDS/HIV
Osteoporosis or bone tumor
Do you smoke:
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No
Yes
Would you like to discuss these questions in private with the dentist?
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No
Yes
Do you have an artificial hip, heart valve or other prosthetic implant?
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No
Yes
Have you ever had problems with dental treatment?
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No
Yes
Are you taking any drugs, medicines or tablets?
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No
Yes
Female patients, are you pregnant?
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No
Yes
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