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PATIENTS WELCOME
02 9371 6605
About
Dr Andrew Maratos
Privacy Policy
Cosmetics
Crowns and Bridges
Invisalign®
Whiter teeth in 1 hour
Veneers and Bonding
White Fillings
Mouthguards
Root Canal Therapy
Periodontal Therapy
Dentures
Night Guards or Splints
Implants
Multiple Teeth Replacement
Single Tooth Replacement
Emergency Dental
Technology
Air Abrasion
Cone Beam 3D Computed Tomography
Digital X-Rays
Laser Dentistry
Prophy-Jet Clean
Strict Infection Control
Special Offer
Contact Us
Medical History Form
Mr
Mrs
Miss
Ms
Dr
Surname
First Name
Date Of Birth
Recommended By
Address
Post Code
Private Phone
Mobile Phone
Business Phone
Email
Occupation
Person responsible for fees (if not self):
Address of fee payer
Post Code
Purpose of visit
Dental Insurance
Insurance provider
Policy Number
Is another member of your family a patient at our office:
Name
Any Heart Problems
Yes
No
Circulatory Problems
Yes
No
Blood Pressure
Yes
No
Radiation Treatment
Yes
No
Artificial Joints
Yes
No
Excessive Bleeding
Yes
No
Rheumatic Fever
Yes
No
Excessive Bruising
Yes
No
Ulcers (stomach)
Yes
No
Anaemia or other Blood Disorders
Yes
No
Sinus Trouble
Yes
No
Diabetes
Yes
No
Artificial Heart Valves
Yes
No
Asthma
Yes
No
Infectious Diseases
Yes
No
Hepatitis
Yes
No
Allergies to Anaesthetics
Yes
No
Epilepsy
Yes
No
Allergies to Penicillin
Yes
No
Liver or Kidney Problems
Yes
No
Allergies to Medications
Yes
No
Tumour/Cancer History
Yes
No
Allergies to Latex
Yes
No
Hormone Replacement Therapy
Yes
No
Are you currently taking any drugs or medicines?
Yes
No
Does your jaw “click” or hurt?
Yes
No
List medications:
Do you feel you grind your teeth?
Have you ever had orthodontic treatment?
Yes
No
Do you think you have occasional bad breath?
Yes
No
Do you wear a dental night guard?
Do your gums ever bleed when you clean your teeth?
Have you ever had periodontal (gum) treatment?
Yes
No
Do you experience sensitivity with hot/cold?
Yes
No
Have you ever had your bite adjusted?
Yes
No
Do your teeth ever hurt when you bite hard?
Yes
No
Do you bite your lips or cheeks often?
Yes
No
Does floss ever tear between your teeth?
Yes
No
Do you smoke?
Yes
No
Does food get jammed between your teeth?
Yes
No
Amount per day
Is there anything else you would like us to know?
*
The name of your physician
How long since you last dental appointment?
Address of physician
Post Code
How often do you have dental examinations?
Monthly
3 Monthly
6 Monthly
Yearly
2 Yearly
2+ Yearly
Previous dental x-rays were taken
Less than 1 year
More than 1 year
Are you pregnant?
Yes
No
Due Date
Name
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About
About us
Dr Andrew Maratos
Privacy Policy
Cosmetics
Cosmetic Dentistry
Crowns and Bridges
Invisalign®
Whiter teeth in 1 hour
Veneers and Bonding
White Fillings
Implants
Dental Implants
Multiple Teeth Replacement
Single Tooth Replacement
Emergency Dental
Technology
Our Technology
Air Abrasion
Cone Beam 3D Computed Tomography
Digital X-Rays
Laser Dentistry
Prophy-Jet Clean
Strict Infection Control
Special Offer
Practice Gallery
Patient Information
Medical History Form
Smile Assessment Form
FAQS
Contact Us