Pakenham Shine Dental
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About us
Dr Rose Mathew
Services
General Dentistry
Oral Examination
Dental X-Rays
Dental Extraction
Teeth Cleaning
White Fillings
Mouthguards
Child Dental Benefit Schedule
Root Canal Treatment
Cosmetic Dentistry
Crown and Bridge
Dental Implants
Preventive Dentistry
General Dentistry
Oral Examination
Dental Extraction
X-rays
Teeth Cleaning
White Fillings
Mouthguards
Child Dental Benefit Schedule
Root Canal Treatment
Cosmetic Dentistry
Crown and Bridge
Dental Veneers
Dentures
Whitening & Bleaching
Orthodontic Treatment
Dental Implants
Preventive Dentistry
Fissure Sealants
Gallery
Review
Blog
Contact us
Home
About us
Dr Rose Mathew
Services
General Dentistry
Oral Examination
Dental X-Rays
Dental Extraction
Teeth Cleaning
White Fillings
Mouthguards
Child Dental Benefit Schedule
Root Canal Treatment
Cosmetic Dentistry
Crown and Bridge
Dental Implants
Preventive Dentistry
General Dentistry
Oral Examination
Dental Extraction
X-rays
Teeth Cleaning
White Fillings
Mouthguards
Child Dental Benefit Schedule
Root Canal Treatment
Cosmetic Dentistry
Crown and Bridge
Dental Veneers
Dentures
Whitening & Bleaching
Orthodontic Treatment
Dental Implants
Preventive Dentistry
Fissure Sealants
Gallery
Review
Blog
Contact us
Book Now
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Facebook
Menu
Home
About us
Dr Rose Mathew
Services
General Dentistry
Oral Examination
Dental X-Rays
Dental Extraction
Teeth Cleaning
White Fillings
Mouthguards
Child Dental Benefit Schedule
Root Canal Treatment
Cosmetic Dentistry
Crown and Bridge
Dental Implants
Preventive Dentistry
Gallery
Review
Blog
Contact us
Book Now
Instagram
Facebook
form
Title
Mr.
Mrs.
Miss.
Ms.
Dr.
Name
Surname
DOB
Address
Post Code
Email
Telephone Home
Mobile
Telephone Home
Postal Address (If different from above)
Emergency contact name, number and relationship
Medicare number & Ref
EXP
Name
Health insurance card number
reference no
EXP
How did you hear about Shine dental Group
Website
Advertising
Personel Recommendation
Health Engine
Others
Person responsible for payment: (if not you please fill section below)
Myself
Others
name
surname
DOB
Phone Home
Work
Mobile
Address
Post Code
Physician's Name
Telephone
(women) Are you Pregnant?
No
Yes
Have you had any of the following?
Arthritis/Rheumatism
Artificial Joints (knee, hip etc.)
Asthma
Blood pressure High or low
Cancer, Tumour or other malignancy
Chest pain
Congenital Heart disease
CJD: High / low Risk
Heart alignment (heart attack, coronary artery disease, cardiac surgery)
Heart Murmur
Hepatitis or Liver disease
HIV / AIDS
Kidney Disease
Osteoporosis or any other bone disorder
Radiation or chemotherapy
Diabetes
Disability (physical or developmental)
Emphysema or other lung disease
Epilepsy
Excessive bleeding or blood disorder
Rheumatic fever
Special Needs (Autism, Developmental Delay etc.)
Stroke or other CVA
Teberculosis
Have you had any previous illnesses? (if yes please state below)
Have you ever been advised to take antibiotics before dental treatment?
Yes
No
Do you have any allergies/allergic to any medication?
List medications you are currently taking:(also in particular medications for osteoporosis, blood thinners eg warfarin which can affect the dental treatment provided )
Have you ever had any compilations following dental treatment?
Yes
No
Reason for today's visit?
Former Dentist:
Approximate date of last dental visit
Please tick if the following apply to you
Bad breath
Broken fillings
Blister on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cosmetic improvement/Makeover
Dry Mouth
Food collection between the teeth
Clench or grind teeth
Growths or sore spots in your mouth
Gums swollen, tender or bleeding
Jaw pain or tiredness
Lip or Cheek biting
Loose tooth
Orthodontics (Braces)
Sensitivity to pressure or irritants (cold, hots or sweets)
Tooth replacement options (dentures, crowns, bridges, implants)
Wisdom teeth problems
Other
Privacy Agreement & Patient Consent
I understand the shine dental group and associated Medical & Dental clinics comply with the privacy act (1988) and as part of their privacy are committed to protecting the privacy of individuals and their personal information. by ticking and submitting below indicates that i have read the above and consent to Shine Dental Group collecting, using, storing and disposing of my personal information; the release of relevant personal information to other health professionals to allow quality dental care; inclusion in a recall register to be advices of the following up visits. I understand I may withdraw my consent for Shine Dental group to us and disclose my personal information (except when legal obligations must be met).
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