Personal DetailsFull Name(Required) Preferred TitleMissMrs.Ms.SisterDr.Prof.Mr.Rev.Other Prefix Full Name(Required) First Last Address Home Street Address Home Street Address Line 2 Town/City Suburb Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench 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Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Home PhoneMobile PhoneDate of Birth DD slash MM slash YYYY OccupationWork PhoneAddress Home Street Address Home Street Address Line 2 Town/City Suburb Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact NameEmergency Contact PhoneMedical HistoryHow did you hear about Dr Tam's practice?How did you hear about Dr Tam's practice?FacebookGoogleWord of mouth (friends or family)Referred by ClinicianName of Referring ClinicianChoose a Location(Required)Choose a LocationNewmarketdevonportName of Physician/and their specialtyMost recent physical examination DD slash MM slash YYYY PurposeWhat is your estimate of your general health? Excellent Good Fair Poor Do you have or have ever had an allergic reaction to Aspirin, Ibuprofen, Acetaminophen, Codeine Local-Anesthetic Penicillin Fluoride Erythromycin Metals (Nickel, Gold, Silver) Tetracycline Latex Sulfa Other Do you have or have ever had Hospitalization for illness or injury Heart problems, or cardiac stent within the last six months History of infective endocarditis Artificial heart valve, repaired heart defect (PFO) Pacemaker or implantable defibrillator Orthopedic implant (joint replacement) Rheumatic or scarlet fever High or low blood pressure Stroke (taking blood thinners) Anemia or other blood disorder Prolonged bleeding due to a slight cut (INR > 3.5) Emphysema, shortness of breath, sarcoidosis Tuberculosis, measles, chicken pox Asthma Breathing or sleep problems (i.e. sleep apnea, snoring, sinus) Kidney disease Liver disease Jaundice Thyroid, parathyroid disease, or calcium deficiency Hormone deficiency High cholesterol or taking statin drugs Diabetes (HbA1c) Stomach or duodenal ulcer Digestive disorders (i.e. celiac disease, gastric reflux) Osteoporosis/osteopenia (i.e. taking bisphosphonates) Arthritis Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma) Glaucoma Contact lenses Head or neck injuries Epilepsy, convulsions (seizures) Neurologic disorders (ADD/ADHD, prion disease) Viral infections and cold sores Any lumps or swelling in the mouth Hives, skin rash, hay fever STI / STD / HPV Hepatitis HIV / AIDS Tumor, abnormal growth Radiation therapy Chemotherapy, immunosuppressive medication Emotional difficulties Psychiatric treatment Antidepressant medication Alcohol / recreational drug use Botox / Dermal Fillers Are you Presently being treated for any other illness Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea) Taking medication for weight management Taking dietary supplements Often exhausted or fatigued Experiencing frequent headaches A smoker, smoked previously or use smokeless tobacco Considered a touchy / sensitive person Often unhappy or depressed Taking birth control pills Currently pregnant Prostate disorders Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)List all medications, supplements, and or vitamins taken within the last two years.PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.Dental historyHow would you rate the condition of your mouth? Excellent Good Fair Poor Previous DentistHow long have you been a patient?Date of most recent dental exam DD slash MM slash YYYY Date of most recent x-rays DD slash MM slash YYYY Date of most recent treatment (other than a cleaning) DD slash MM slash YYYY I routinely see my dentist everyI routinely see my dentist every3 months4 months6 months12 monthsNot routinelyWhat is your most immediate concern?Personal History Are you fearful of dental treatment? Have you had an unfavorable dental experience? Have you ever had complications from past dental treatment? Have you ever had trouble getting numb or had any reactions to local anesthetic? Did you ever have braces, orthodontic treatment or had your bite adjusted? Have you had any teeth removed or missing teeth that never developed? If you are fearful of dental treatment, how fearful are you, on a scale of 1 (least) to 10 (most)12345678910Gum and bone Do your gums bleed or are they painful when brushing or flossing? Have you ever been treated for gum disease or been told you have lost bone around your teeth? Have you ever noticed an unpleasant taste or odor in your mouth? Is there anyone with a history of periodontal disease in your family? Have you ever experienced gum recession? Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? Have you experienced a burning or painful sensation in your mouth not related to your teeth? Tooth structure Have you had any cavities within the past 3 years? Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth? Do you have grooves or notches on your teeth near the gum line? Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? Bite and jaw joint Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) Do you feel like your lower jaw is being pushed back when you bite your teeth together? Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? Have your teeth changed in the last 5 years, become shorter, thinner or worn? Are your teeth becoming more crooked, crowded, or overlapped? Are your teeth developing spaces or becoming more loose? Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together? Do you place your tongue between your teeth or close your teeth against your tongue? Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? Do you clench your teeth in the daytime or make them sore? Do you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth? Do you wear or have you ever worn a bite appliance? Smile characteristics Is there anything about the appearance of your teeth that you would like to change? Have you ever whitened (bleached) your teeth? Have you felt uncomfortable or self conscious about the appearance of your teeth? Have you been disappointed with the appearance of previous dental work? Photography I consent to photographs being taken if required to evaluate treatment effectiveness or for dental education and training. After consultation, if I agree, such photos could be used for professional publications or sales purposes. No photographs revealing my identity will be used without my consent. Treatment suitability via Digital Smile Design analysis if required.*PRIVACY POLICY We are committed to acting in accordance with the Privacy Act 1993 by providing you with a service that meets your requirements in a way that doesn’t affect your privacy. We collect your personal information for the purpose of conducting our business and providing you with quality dental care. We collect personal information from you directly and the type of information we generally collect and store may include but is not limited to your name, address, date of birth, gender, contact details including phone, fax and email, occupation and your medical history. Collection occurs when you complete a medical history form upon requesting a service from us.We endeavour to maintain that the personal information we collect is accurate, complete and up-to-date. The Act also gives you the right to request access to any or all of your personal information held by us.We will not sell or lend your personal information to other companies or persons who are not part of our business group. We may however in the course of operating our business disclose your personal information to service providers who assist us, for example, dental specialists. Where this happens service providers are subject to strict privacy rules and can only use the information for the function we have asked them to perform. PAYMENT OF ACCOUNTS 48 hours notice of appointment rescheduling or cancellation is required. Failure to do so may result in a overhead coverage fee of $300 per clinical hour. Payment for all services is due at each appointment. Finance option – we accept Q Card, this can be applied for through our website. Accounts with a balance more than 30 days overdue will receive a reminder notice with invoice. Accounts with a balance of more than 120 days outstanding may be sent to debt collection with one week’s notice. Any expenses incurred in the recovery of debt, including but not limited to legal and debt collection costs, shall be claimed on the patient.Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use.PhoneThis field is for validation purposes and should be left unchanged.