Health History Form
Private and Confidential

In signing this form, I acknowledge that the above information represents an accurate medical history and that I will advise my dentist of future changes to my health status/medical care requirements. I understand my details will be treated with complete professional confidentiality. I consent to sharing appointment times & dates with members of my immediate family. I will notify Sage Dental in writing if my family circumstances change and do not wish for this to happen.

I hereby authorise the dentist or designated team to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. 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. I agree to the use of anaesthetics, sedatives 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.

I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is required at the time of service unless other arrangements have been made. I will be liable for all costs incurred by Sage Dental in recovering or attempting to recover accounts/debts including costs, debt collection fees & legal costs.