HomeConsent & Medical History Form Consent & Medical History Form "*" indicates required fields Full Name* Email* Please check any illnesses or conditions you have ever had: Allergies to latex, CHX or iodine Other allergies Asthma Artificial Joint Angina artificial heart valve Bleeding disorder COPD Cardiac surgery/pacemaker Congenital heart defect, heart disease, heart murmur Diabetes 1 2 Epilepsy High/Low blood pressure Stroke Do you have a salt reduced diet?* Yes No Have you had any joint replacements in the last 6 months?* Yes No Are you taking any blood thinner medication?* Yes No Do you have any other medical conditions we should be aware of?* Yes No Please specify: For women: Are you breastfeeding? Yes No For women: Are you pregnant? Yes No What trimester are you in?* Consent*I understand the clinician-on-clinician training is not providing an examination, a diagnosis or therapeutic treatment. The treatment is for education purposes only. I am consenting to receiving treatment as part of educational purposes and understand it does not replace the need for professional dental care. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving a reason and without cost. I understand that I will be given a copy of this consent form via email. Yes, I understand*Consent*It is a requirement by AHPRA that closed in shoes, gowns and glasses are worn to take part in the clinical session of the day. Yes, I understand*PhoneThis field is for validation purposes and should be left unchanged.
