Adult Consent Form Centre Name/ Location First Name Last Name Date Of Birth (DD/MM/YYY) Phone Number Home Address Email Address Emergency Contact Name Emergency Contact Number Payment Options You are welcome to pay at the time of your consultation via cash or credit card. Alternatively please provide your payment details below. No amounts will be debited from your card until after your consultation. Pay By Credit Card Name on Credit Card Credit Card Number Expiry Date (MM/YY) CCV Amount Payable Pay By Direct Deposit Account Name: Future Skills Network Group BSB: 012 110 Account Number: 295987518 Please use your full name as reference. Pay By Paypal To pay via PayPal, download the PayPal app or log onto the PayPal website. When asked, our email address is firstname.lastname@example.org. Follow the prompts from there to pay $99 for the service. Medical History Questionnaire Please provide details or discuss them with your dentist. Information about your medical history is for your dentist’s use only Past/current medical conditions Are you receiving any medical treatment at present? Have you had any serious or long standing illness? Have you ever been hospitalised? Please indicate if you have EVER had any of the following: Any heart complaint/ treatment---NoYes Any nervous system disorder---NoYes Rheumatic fever or heart valve surgery---NoYes Asthma/bronchitis/lung conditions---NoYes High or low blood pressure---NoYes Radiation therapy / chemotherapy---NoYes Blood disorders / bleeding disorders---NoYes Thyroid disease---NoYes Epilepsy---NoYes Hepatitis, jaundice or liver disease---NoYes Diabetes---NoYes Treatment for any form of cancer---NoYes Thyroid disease---NoYes Familial diseases---NoYes Transplanted organ or bone marrow---NoYes Infectious disease (measles/chicken pox), especially in the last three weeks---NoYes Kidney conditions---NoYes Tuberculosis---NoYes Do you smoke?---NoYes Please provide details if you answered yes to any of the above Current Medications Allergies eg. latex, penicillin, etc. By clicking send you agree that the information provided above is a true and accurate record. Please note, this form is a guide only and you should discuss any relevant matters with your dentist prior to the commencement of any dental treatments. Please see our website for our privacy statement.