07 4191 4787
8/6-8 Liuzzi St, Pialba QLD 4655
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Scale and Clean
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Inlays & Onlays
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Implant Dentistry
Single/Multiple Implants
All-on-4
Sinus Graft/Lift
Bone Grafting
Orthodontics
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Early Treatment
Children’s Orthodontics
Teen’s Orthodontics
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Check-Up
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Fissure Sealants
Tongue Ties
Muscle Training
Oral Hygiene Education
Child Dental Benefits Schedule
Lakeside Dental Spa for kids
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Objective of the Program
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Medical History Form
Welcome To Our Practice!
Please complete the following confidential questionnaire, which will assists us in providing you with quality dental care.
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Date Of Birth
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Parent/Guardian names if under the age of 16
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Are you in a Private Health Fund for Dental?
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If yes, which onealthfor Dental Fund ?
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If yes, card number?
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Diabetes
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Heart Conditions or Heart Surgery
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Arthritis
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Excessive Bleeding
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Asthma or Bronchitis (Which one?)
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Rheumatic Fever
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HIV or Hepatitis A,B or C (Which one?)
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Hip/Knee Replacement (Which one?)
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Epilepsy
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No
Anxiety or Depression (Which one?)
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Hay Fever or Sinus
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Allergies
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Ladies, are you pregnant?
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Radiation therapy to the head or neck
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Treatment therapy for cancer
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Diseases of bone/other cancer that has spread to the bone (eg: osteoporosis, pagets disease) Include any medications taken for this:
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