Have you ever had any of the following?

Please answer the following:

Consent for treatment

By signing this form I acknowledge that this represents an accurate medical history. I agree to advise the dentist of any changes to my medical history in the future. I authorise the dentist to discuss my clinical treatment with other medical and dental practitioners and specialists if needed. I understand this information may be viewed by other staff members of the practice and that all information will be treated with confidentiality under the guidelines of the Privacy Act of 2002.