We ask you to provide the following pre-treatment information. The information we collect enables us to provide you with
better care. Your privacy is important to us, so all information provided will be kept strictly confidential.
YOUR DETA Title : Mr Mrs Ms Miss Dr Others________________
Given Name : ____________________________ Preferred Name : __________________________ Surname : ________________________________
Date of Birth : ________________________________________
Postal Code : ______________________________________________________
Home Address : _______________________________________________________________________________________________________________
Mobile Phone : ________________________________ Home Phone : _____________________________
Email : ______________________________________________
BUSINESS CONTA CT DETAILS
Your Occupation : ____________________________________________________ Work Phone : ____________________________________________
Business Name : ______________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Postal Code : ___________________________
EMERGENCY CONTACT DETAILS
Name : ___________________________________________________ Contact No. : _____________________________________________________
Relationship to you : _________________________________________
DENTAL IN FORMATION
What is the purpose of your visit today : _____________________________________________________________________________________________
Have you had any problems with past dental treatment? Yes No
If yes, please explain : ___________________________________________________________________________________________________________
If Yes, Which one? ____________________________ Membership No. : ______________________________ Ref No : ___________________________
No Card No. :_________________________________
How did you hear about this practice? _______________________
To whom shal we make your accounts payable? ____________________________
I have read and understand Beyond Smiles Privacy Policy. I understand that payment is required on the day of treatment. Cash EFTPOS Credit Card Patient/Guardian Name/Signature : _________________________________________ Date : ____________________________________________ Failure to give 48 hours notice for appointment changes may incur a cancellation fee. CONFIDENTIAL HEALTH INFORMATION
Name of your general Medical Doctor : _________________________________________ Phone : __________________________________________
Address : ___________________________________________________________________________________________________________________
Are you being treated for a medical condition at present? ____________________________________________________________________________
Are you taking any medications or supplements at present, both prescribed or over the counter? (Please List)
__________________________________________________________________________________________________________________________
Do you have, or have you ever had, any of the following medical conditions?
Do you have any al ergies? (Penicil in, codeine, nickel, latex)
Please Specify : _____________________________________________________________________________________________________________
Do you take any prescribed drugs, tablets, medicines, or creams?
Please Specify : ____________________________________________________________________________________________________________
Have you ever been given medication for Osteoporosis or Osteoponeia?
Have you taken bisphosphonate medications? (Didronel, Fosamax, Aredia, Pamisol, Actonel, Zometa, Bonefos, Skelid or Bonviva)
How long have you been on the medication? _______________________ When did you last take them? ____________________________________
Have you even had any adverse reactions or allergic reactions to any treatment or medications?
Please Specify : ____________________________________________________________________________________________________________
Do you have a heart murmur, or artificial heart valve?
Do you have any prosthetic body parts? (eg. Artificial hip shoulder or knee joints)
Please Specify : ____________________________________________________________________________________________________________
Ladies, are you pregnant, undergoing fertility treatment or family planning?
If so, how many weeks?______________________________________________________________________________________________________
If so, how many?____________________________________________________________________________________________________________
Patient/Guardian Name/Signature : ____________________________________________________ Date : _____________________________________________
Assessing the Potential Value of Rare Metals in Urban Mines: A Comparative Look at Korea and Japan By JUNG Ho-Sung Co-authored by KIM Hwa-Nyeon and CHOI Myeong-Hae September 2011 I. The Rise of Rare Metals Rare metals refer to metals which are scarce in the earth’s crust, or which are scarce because they are difficult to extract and process. Rare metals are also met
Medical Information Dowling Catholic High School Instrumental Music Department Student name: ___________________________________ Grade: _________ Birth date: ________________ Address: ________________________________________ Home phone: ______________________________ Parent/Guardian: ________________________________ Work phone: ___________ Cell phone: _________ Parent/Guar
We ask you to provide the following pre-treatment information. The information we collect enables us to provide you with
better care. Your privacy is important to us, so all information provided will be kept strictly confidential.
YOUR DETA