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

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EMERGENCY CONTACT DETAILS



DENTAL/MEDICAL HISTORY

6 to 12 Months1 to 2 years3 to 5 years5 years +

ArthritisNoYes
Blood ThinnersNoYes
High Blood PressureNoYes
Liver/Kidney DiseaseNoYes
OsteoporosisNoYes
ThyroidNoYes
AsthmaNoYes
Cancer/MalignanciesNoYes
Mental illness/DepressionNoYes
Low Blood PressureNoYes
Rheumatic FeverNoYes
SmokingNoYes
Immune DeficienciesNoYes
HIV (Blood Born Virus)NoYes
Diabetes (Type I or II)NoYes
Heart ProblemNoYes
Joint replacementNoYes
SinusNoYes
Hepatitis A/B/CNoYes



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CONSENT
All 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.