Adult Consent Form


Centre Name/ Location

Last Name

Date Of Birth (DD/MM/YYY)

Phone Number

Home 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 accounts@fcmdental.com.au. 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
Any nervous system disorder
Rheumatic fever or heart valve surgery
Asthma/bronchitis/lung conditions
High or low blood pressure
Radiation therapy / chemotherapy
Blood disorders / bleeding disorders
Thyroid disease
Epilepsy
Hepatitis, jaundice or liver disease
Diabetes
Treatment for any form of cancer
Thyroid disease
Familial diseases
Transplanted organ or bone marrow
Infectious disease (measles/chicken pox),
especially in the last three weeks
Kidney conditions
Tuberculosis
Do you smoke?

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.