Medical Questionnaire

Dentists must update a patient’s medical status annually to ensure accurate and up-to-date information for safe and effective dental care.

Receive a *25% discount by completing below!

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Patient & Contact Details

We deidentify the health information you provide here using details to identify you, which only we can decode.

How did you set your dental appointment?
Check the SMS or email with the link to this form for your Unique Patient Identifier.
We use the patient's first name and linked mobile phone to help identify you. Please do not provide the patient's full name.
Age of the patient in years.
The phone number you provided when setting the dental appointment for yourself or your dependent. It helps up identify the patient.
Select which units of measure you will use for your height and weight.
Who completed this form?


Snoring and sleepiness during the day can be a symptom of sleep apnea. It can also impact oral health by increasing the risk of issues like dry mouth, tooth decay, gum disease, and tooth grinding.

Do you snore, or have you been told that you snore?
Have you ever undergone a sleep study?

Other Medications

These items can harm oral health and influence our treatment plan to optimise it.

Are you taking other prescription medications, supplements, inhalers, and over-the-counter medicines not already listed above?

Recent Medication

Informing your dentist about recently discontinued medications is crucial, as certain drugs can have lingering effects or interact with dental treatments.

Have you taken and stopped any prescription, non-prescription, alternative medicines or supplements in the last two months?

Recreational Substances

These substances can have lingering effects on oral health and may impact the success of dental treatments.

Have you ever taken any recreational substances such as marijuana, cocaine, ecstasy, MDMA…?

Vaccination Status

The dentist must know your vaccination status to ensure appropriate preventive measures and customise treatment plans based on your immunity to infectious diseases, promoting optimal oral health care.

Are you up-to-date with your vaccinations such as dTpa, Influenza B, Hepatitis B, Rotavirus, Yearly-Influenza (Flu), Meningococcal ACWY and Phenumoccal?

Declaring Accuracy!!!

Declaring the accuracy of the medical history provided is vital for proper treatment, informed decisions, and patient safety.

If you think you may have answered incorrectly, please scroll back and edit the response before clicking the Next button.

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Understanding Your Medical History

A Medical Histtory is Essential for Safe Effective Dental Care_READ MORE

Medical & Medication History

Information about your medical and medication history is essential for safe and effective dental care.

Please take the time to complete this form as accurately as possible. At your next visit, you can discuss anything you are unsure about with your dentist.

Completing this form will give the dentist more time during your visit to focus on the dental care you seek with your safety in mind.

  • The 25% discount applies to your standard consultation fee; it does not apply to any treatment provided at the appointment.

Guarding Patient Confidentiality: A Top Priority

Patient Confidentiality_READ MORE

Patient Confidentiality

At Riverina Dental Albury, we uphold patient confidentiality and privacy in all our services, including online form submissions. When you submit forms through our website, rest assured that we take the utmost care to ensure the security and confidentiality of your personal information.

We employ state-of-the-art security measures to safeguard the data you provide, and our staff are trained to handle patient information with the highest level of discretion and professionalism. Our top priority is your privacy, and we adhere to all relevant privacy laws and regulations to protect sensitive information.

It’s important to note that we do not use personal identifiers such as full names in these forms. By omitting personal identifiers, we further enhance the confidentiality of the information you submit. Your privacy and anonymity are central to our commitment to maintaining the highest standards of patient confidentiality.

By submitting forms online, you can trust that your details, medical history, and other information are handled with the strictest confidence. Our commitment to patient confidentiality extends to all interactions with our practice, whether in person or online.

If you have any concerns about the privacy and security of your information when submitting forms online, please do not hesitate to contact us. Riverina Dental Albury is dedicated to providing you with the highest standard of care, including ensuring the privacy and confidentiality of your personal information. Thank you for entrusting Riverina Dental, Albury, with your dental care.

Yours sincerely

Dr Denver Maloney BDS (Syd) 1989

Dental Surgeon | Practice Principal