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.* YES No Please Select Mr Mrs Ms Miss Master Dr Name* First Last Email* Phone*Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Work* Date of Birth* MM slash DD slash YYYY Parent/Guardian names if under the age of 16: Are you in a Private Health Fund for Dental?* Yes No If yes, which one? Are you covered by Veterans Affairs?* Yes No If yes, card number? How did you find out about Our Practice?* Advertising Family & friends Internet Walk-in/Seen the sign Yellow Pages Other Have you ever had or do you have any of the following? (Please tick)High Blood Pressure Yes No DiabetesDiabetes Yes No Heart Conditions or Heart SurgeryHeart Conditions or Heart Surgery Yes No ArthritisArthritis Yes No Excessive BleedingExcessive Bleeding Yes No Asthma or Bronchitis (Which one?)Asthma or Bronchitis (Which one?) Yes No Rheumatic FeverRheumatic Fever Yes No HIV or Hepatitis A,B or C (Which one?)HIV or Hepatitis A,B or C (Which one?) Yes No Hip/Knee Replacement (Which one?)Hip/Knee Replacement (Which one?) Yes No EpilepsyEpilepsy Yes No Anxiety or Depression (Which one?)Anxiety or Depression (Which one?) Yes No AllergiesAllergies Yes No Ladies, are you pregnant?Ladies, are you pregnant? Yes No N/A Radiation therapy to the head or neckRadiation therapy to the head or neck Yes No Treatment therapy for cancerTreatment therapy for cancer Yes No N/A Diseases 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* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.