If you are a new patient requesting an appointment, we will need you to complete a medical history questionnaire providing us with information that will help us to treat your individual needs. This can be done at our practice before your appointment, online or you can print out our medical history questionnaire to complete at your leisure before your appointment.

Please fill in the online form below or if you prefer, please download Word version of the form and email the form to info@rawsondental.com.au

Click for PDF version of  Rawson Dental Medical Form

Welcome to Rawson Dental

Thank you for giving us the opportunity to care for your oral health and smile. In order to provide high standard of care and treatment, please review and complete the following questionaire. It will be handled confidentially.
















Internet/WebsiteYellow PagesWalked pastLetter DropDentist/ DoctorRecommendedOther



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Have you had any of the following dental issues?
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Less than a year ago?Longer than a year ago?

Consent for Treatment

I hereby authorise the dentist or designated team to take x-ray, 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 understand I can ask for a complete recital of any complications associated with treatment I may need. I agree to be responsible for payment of all sevices rendered on my behalf and on behalf of my dependents. I understand that payment is due at the end of service unless other arrangements have been made. I authorise that this information may be reviewed by team members of the dental practice.



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