Have you returned from overseas or interstate travel in the past 14 days?* Yes No

Have you felt unwell, including but not limited to symptoms of COVID-19 such as fever, cough, sore throat or shortness of breath?* Yes No

Have you had any contact with a confirmed or suspected case of COVID-19 in the past 14 days?* Yes No

Please inform The Family Dental Caboolture of any change in your circumstances. Please note that COVID-19 may result in you being referred or treatment deferred.

By signing this form you agree to our terms and conditions.
1. Any information that is collected and maintained is in accordance with state and Federal Privacy Legislation.
2. To the best of my knowledge, I have accurately completed this medical history form.
3. I hereby give my authority for any treatment to be carried out by the dentists and their staff.
4. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made.
5. I authorise the dentist to take images of my teeth both before and after my treatment. I understand these images may be used in the practice portfolio to showcase examples of dental work to other patients and my identity will remain anonymous.
6. All specials, treatment plans and price lists are subject to change at the practice's discretion without notice.