Adults - Bounce official webpage

1Patient Information

2Medical History

3Consent

Name*

First name Last name

Address*

Street Address Address Line 2 City ZIP / Postal Code

Phone*

Email*

Gender*

Date of birth*

DD slash MM slash YYYY

Do you have Private Health Insurance*

Where do you work*

Preferred Appointment Day*

Monday

Tuesday

Wednesday

Thursday

Friday

Do you have any allergies?*

Which allergie(s) do you have?

Do you have/have you had any serious*

Please indicate if you have / had any of the conditions below. If any are ticked, please supply further information.

Any heart complaint / treatment

Rheumatic fever or heart valve surgery

High or low blood pressure

Epilepsy

Diabetes

Infectious disease (Measles / Chicken Pox)

Tuberculosis

Any nervous system disorders

Asthma / Bronchitis / Lung Conditions

Thyroid disease

Hepatitis

Treatment for any form of cancer

Transplanted organ or bone marrow

Kidney conditions

Additional information:

Are you currently taking any medication?*

Please list any other conditions that may affect your treatment, so the Bounce Dentistry clinical team can meet their specific needs:

Have you ever been hospitalised?*

Please tick all that apply*

I give consent to a dental assessment, scale, clean & remineralising treatment carried out by Bounce Mobile Dentistry.

I understand that payment for treatment is required prior to treatment. A full refund will be issued if appointment is not attended.

I hereby give consent for the use of my photo / video material to be utilised by the company for the marketing / social media.

Yes

I, the patient / legal guardian, certify that I have been informed:

Of the treatment that has been or will be provided from this date;
Of the likely cost of this treatment;

I agree that the above is true and accurate information has been given. I understand that all information including all photos will be kept private and confidential which Totally Smiles collect during all stages.

Consent*

Yes, I have read and understood the information listed above.

CAPTCHA

Initials*

Date*

DD slash MM slash YYYY

Phone

This field is for validation purposes and should be left unchanged.

Consent Form – Adult

I, the patient / legal guardian, certify that I have been informed:

Fields marked with an * are required