Mr. John Appleyard: Consultant Dental Surgeon Albury Wodonga

Mr. John Appleyard, B.D.S. (Adel.) Consultant Dental Surgeon

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Comprehensive Consultation

Includes Oral Cancer Check, Soft and Hard Tissue exam, Jaw Joint Analysis, and laser Caries Diagnosis - The most advanced European method for early detection of decay especially in children. It can reduce the need for x-rays, but does not replace them.

Fees: $57 Standard, $98 Extended.

Your Medical history should be updated regularly.

*Name:

*Phone : (H)

Date Of Birth :

Prefered appointment Date/Time :

Address:

(W) :

Occupation & Employer:

Payment is to be made at the end of each appointment, regardless of whether you have Health Insurance.
We have Optus Health claims available so you may instantly arrange for your rebate to be credited to the practice, leaving only the gap amount to pay, EFT-POS is also avilable.

MEDICAL HISTORY QUESTIONNAIRE Please read this document carefully, and answer all questions accurately. The information is in confidence, and enables me to provide treatment appropriate to your medical condition. Many drugs taken, and disease states, will of necessity change the possible choices for your optimal dental treatment. Why do we ask these questions? Diabetics have a delayed healing time, and endodontics may not be suitable. Anti-hypertensive drugs (high BP) may cause adverse reactions if certain local anaesthetics drugs are being used. Many people take anti-coagulants, and this prolongs bleeding times if surgery is required. Angina patients need to bring their tablets to all appointments. The contraceptive pill (and HRT) interacts with antibiotics to such an extent that alternate methods of contraception need to be used. Some local anaesthetics are contraindicated due to severe side affects if Viagra has been recently used. Liver disease prolongs bleeding times. Rheumatic Fever patients require antibiotics coverage for certain dental procedures to prevent the possibility of further heart valve damage. Shortness of breath may be a symptom of an underlying cardiac or respiratory problem.
With which company is your private Health Insurance?: Does this include Dental Cover?: Yes No Have you ever had an Allergic or Adverse reaction to any drugs? Yes No Please give details: Have you had a general anaesthetic? Yes No		Do you take Drugs/Medicines Regularly? Yes No If YES, Which ones? Have you had any Health Problems this year? Yes No Who is your usual Medical Doctor? How would you rate your General Health?
Are you happy with your Dental Appearance/Function? Do you suffer from, or have you ever had any of the following? Please click the YES box under the (Yes), if that is the case, and give details in the space provided below. (Other Details Box)

Problems:	Yes	Problems:	Yes
Heart Disease		Shortness Of Breath
Blood Pressure Irregularities		Diabetes
Kidney or Bladder Disease		Allergy or Hypersensitivity
Prolonged Bleeding following Surgery		Females, are you possibly Pregnant*
Females, Do you take the Contraceptive Pill*		Have you ever taken Growth Hormone Products, OR Females, have you ever taken Hormones to promote fertility
Do you take any NON Prescription Drugs		Vascular Disorder
Asthma		Rheumatic Fever
Liver Disease or Hepatitis		Epilepsy or Psychiatric Disorder
Blood Transfusion		Anticoagulant Therapy or recently taken Aspirin
Females, are you on Hormone Replacement Therapy*		Males, Have you used Viagra in the last 24 Hours*
*Yes Answers greatly influence drugs we may safely use		AIDS/HIV (You may inform the surgeon rather than write)
Other Details: * = Required fields

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