Dr. Kay Park & Associates would like to welcome you to Dental Focus and assure you that we will endeavour to make our association pleasant and satisfactory. In order to render dental treatment of high standard, it is necessary to have the following information, which will be handled confidentially. Please fill in this form completely and accurately.PERSONAL DETAILS Title MrsMsMissMrMasterDrOther Surname First Name Birth Date (d/m/y) / JanFebMarAprMayJunJulAugSepOctNovDec / Home Address Post Code Mobile Email Home Phone Do you have Private Health Insurance for dental treatment? YesNo Health Fund How did you hear about us? Walk inInternet SearchHomepageFacebook Medicare Number Reference Expiry Date JanFebMarAprMayJunJulAugSepOctNovDec / EMERGENCY CONTACT DETAILS Name Relationship Contact Number DENTAL/MEDICAL HISTORY When did you last see a dentist? 6 to 12 Months1 to 2 years3 to 5 years5 years + Do you have or have a history of any of the following conditions?ArthritisNoYesBlood ThinnersNoYesHigh Blood PressureNoYesLiver/Kidney DiseaseNoYesOsteoporosisNoYesThyroidNoYesAsthmaNoYesCancer/MalignanciesNoYesMental illness/DepressionNoYesLow Blood PressureNoYesRheumatic FeverNoYesSmokingNoYesImmune DeficienciesNoYesHIV (Blood Born Virus)NoYesDiabetes (Type I or II)NoYesHeart ProblemNoYesJoint replacementNoYesSinusNoYesHepatitis A/B/CNoYes Surgery in the last 2 years Other Allergies (e.g. Penicillin /Latex) Women – Are you pregnant? YesNo How many months Are you a smoker? YesNo List any other Medical Conditions or Medications you are taking and how often: CONSENTAll dental treatments will be discussed before commencement and payment is required on the day of treatment . I consent to the treatment plan and treatment which will be provided by the dental practitioner. I have read and understood the above information. All information provided to Dental Focus are current and correct. I understand that a cancellation fee may apply when 24h notice was not provided. SIGNATURE Date