Patient History Form

To ensure we are looking after your needs, please review and complete the following form:

Have you ever had any of the following?

Do You Suffer From Any Of The Following?

1. I hereby authorise the dentist or designated staff to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.

2. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. I agree to the use of anaesthetics and other medication as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand I can ask for a complete recital of any possible complications.

4. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependants. I understand that payment is due at the time of service unless other arrangements have been made.

Please note: Unfortunately we do not accept American Express, Diners Club or Direct Bank Deposit as forms of payment. We apologise for any inconvenience this may cause. All MasterCard and Visa cards, EFTPOS, Cash & Cheques are accepted.

On behalf of Dr Juric, we thank-you for your assistance.