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Medical History Update

In order for us to maintain up to date records, please provide your contact details below.

Patient Details

Your Address

Unit/Number & Street Name

Emergency Contact

Please provide the details of someone who can be contacted on your behalf if needed.

Your Dentist

Medical Information

Medicare Card
DVA Card
Private Heath Fund

General Practitioner

Do you have a GP we can contact if needed?

Health History

Do you have now, or have you ever had, and of the following medical conditions?
Allergies to any of the following:

Your Current Status

Compensation Claims

Terms & Conditions

Please acknowledge our terms and conditions for the supply of dental services.

Communication

We communicate with our patients on a regular basis.

Privacy Policy & Signature

All personal information collected by Bupa Dental is handled in accordance with our privacy policy. This policy also contains information about how you can request access to your information and how you can make a complaint about the handling of your information. You can view the policy online at https://www.bupadental.com.au/privacy-policy.html.

By signing this form you hereby agree and acknowledge that:

(i) you have accurately completed this new patient/medical history form to the best of your knowledge;

(ii) you consent to any treatment agreed upon, to be carried out by the dentists and their staff;

(iii) you are responsible for payment of all services rendered on your behalf and on behalf of your dependents;

(iv) payment is due at the time of service unless other arrangements have been made; and
(v) your dentist may take images of your teeth both before and after your treatment. These images may be used in a practice portfolio to showcase examples of dental work to other patients (your identity will remain anonymous).
Clear Signature
Use your finger / mouse / stylus to write your signature.
Frequently Asked Questions
What if I don't have all the required information to complete a form?

If you do not have all the required information such as a Medicare card number, you will need to contact your practice's administration staff in-person or by calling them on 9221 2777 (Perth City) 9409 3619 (Kingsway) so they can advise you of how to proceed.

What if I don't know how to get the information I need?

If you're unsure how to get the information you need to complete the form, you will need to contact your practice's administration staff in-person or by calling them on 9221 2777 (Perth City) or 9409 3619 (Kingsway) so they can advise you of how to proceed.

Why can’t I submit my form?

There may be outstanding required fields that you need to answer before submitting your form. You should see each field that requires an answer in a red box at the bottom of your form. Once you have answered all fields, if a signature is required, you must sign your signature electronically using your mouse or fingers in the box provided.

If you are still unable to complete the form, you can fill out the form on paper at the clinic before your appointment.

I’ve already submitted this form, do I need to do it again?

If you have already submitted this form to your practice, you do not need to complete the form again. If you're unsure whether the practice received your form submission, we suggest contacting the practice directly by calling them on 9221 2777 (Perth City) 9409 3619 (Kingsway) to ask them directly.

Still have more questions?
Contact our reception team for more information
9221 2777 (Perth City)
9409 3619 (Kingsway)