Patient History Form

Here at Beenleigh MarketPlace Dental its imperative we know your whole medical history. We use your medical history to help give you individualised and personal dental care.

Please note, all information you provide in this patient history form will remain strictly confidential.

Please fill out the form below, or click to download and print it.

If you have any questions about the form or want to learn more please don’t hesitate to call us and speak to our friendly staff.

Download your patient history form 

  • Date Format: MM slash DD slash YYYY
  • Person responsible for account

    (must be completed if patient under 16, if same as above leave blank)
  • Medical Questionnaire - Private and Confidential

    Please answer these questions fully or discuss them with your dentist. Information about your medical history is for your dentists use only.
  • Past/Current Medical Conditons
  • I agree that the above information is true and accurate record. I understand that payment on the day of treatment is required. Any expenses, costs or disbursements incurred by the Beenleigh Marketplace Dental in recovering any outstanding monies including debt collection fees and solicitor costs shall be paid by the responsible party above. I further acknowledge that failure to attend any appointment without notice may also result in a deposit requirement prior to future appointments being scheduled. I have read and agree with the privacy statement on the back of this document.
  • This field is for validation purposes and should be left unchanged.