7to7 dentists require medical history to create individualised dental plans.It is essential that we are aware of all medications and medical conditions so that we can take steps to prevent any medical conditions being aggravated by our dental treatment.Please reply YES if you're feeling well and have not had a cough, fever, loss of sense of taste & smell, sore throat or shortness of breath, returned from overseas or interstate travel or had contact with a COVID-19 suspected or confirmed case the last 14 days. Please reply NO if you have had any of these. Thankyou.*YESNoPlease SelectMrMrsMsMissMasterDrName* First Last Email* Phone*Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Work*Date of Birth* Date Format: MM slash DD slash YYYY Parent/Guardian names if under the age of 16:Are you in a Private Health Fund for Dental?*YesNoIf yes, which one?Are you covered by Veterans Affairs?*YesNoIf yes, card number?How did you find out about Our Practice?* Advertising Family & friends Internet Walk-in/Seen the sign Yellow Pages OtherHave you ever had or do you have any of the following? (Please tick)High Blood PressureYesNoDiabetesYesNoHeart Conditions or Heart SurgeryYesNoArthritisYesNoExcessive BleedingYesNoAsthma or Bronchitis (Which one?)YesNoRheumatic FeverYesNoHIV or Hepatitis A,B or C (Which one?)YesNoHip/Knee Replacement (Which one?)YesNoEpilepsyYesNoAnxiety or Depression (Which one?)YesNoAllergiesYesNoLadies, are you pregnant?YesNoN/ARadiation therapy to the head or neckYesNoTreatment therapy for cancerYesNoN/ADiseases of bone/other cancer that has spread to the bone (eg: osteoporosis, pagets disease) Include any medications taken for this:Other serious injury or illness:List any medication you are currently taking:GP's Name and location:Signature:Date* Date Format: MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.