Brief history form
Please complete next section if you are under 18:

Medical Summary

Have you had, or do you currently have, any of the following (please circle):
Joint replacement
Heart disease
Do you take bone strengthening drugs?.
Heart murmur
Cancer treatment
Rheumatic fever/Heart valve
Anxiety/mood disorder
Kidney disease
Liver disease
Hepatitis B
Hepatitis C
Asthma/other respiratory problems
Are you pregnant?
Do you have any allergies?
Blood thinning medication (e.g. Warfarin)
High/Low Blood pressure

Maximum file size: 268.44MB

Practice Policies

All payment is required on the day of service. Payments of cash, EFTPOS and credit card are accepted.

Cancelation/No show policy: ” Please kindly note that when you book your appointment with us, especially an emergency one, there is a cancelation policy applicable.

This cancelation policy is set to avoid and prevent leaving out other patients with dental pain to have the limited daily emergency slot. Please be considerate towards our other emergency patients, our staff and the practice’s time.

NEW PATIENT: If you are a NEW PATIENT and cancel your emergency appointment within 72 hours, the cancelation fee may be applicable.

If you have been consulted with us before, or if you are in the middle of your treatment and cancel your non-emergency appointment within 72 hours, the cancelation fee shall be defined as a percentage of your session’s fees. You might be notified by an automated email and the practice’s software automatically will send you an invoice according to your booking reason/s. Please get in touch with us immediately after receiving the invoice. We are here to help you out planning for your missed appointments. 

To avoid disappointments, please make your appointment wisely. Do not double book yourself in another practice especially after you requested an emergency appointment with us.

We have been working hard to accommodate every emergency patient in our limited dedicated daily slot. We also plan according to this to ask our lovely staff stay longer, have shorter breaks and work under pressure. You will always see us smiling, welcoming and caring. We thrive to go above and beyond to make everyone happy and satisfied with our services. Please help us to continue doing the right thing by being good and considerate to us.

Thank you. “

Privacy policy: If you want to view/access to a copy of our privacy policy, please email

All information provided is treated as confidential and this is a medico-legal document.

Please ensure that you read and understand the form before signing.

If you have any queries or concerns please discuss with your endodontist.

Patient Acknowledgement

By submitting this form, I agree with terms and conditions below:

Opening hours

Monday – Friday 9:00 – 17:00
Saturday 10:00 – 14:00
Sunday Closed

About Shahrzad: Your Endodontist in Perth


– Doctor of Dental Surgery (DDS.) Tehran, Iran
– Master of Science (MSc) in Endodontics, Iran
– Iranian National Board certificate in Endoodnics
– Doctor of Clinical Dentistry (DClinDent) in Endodontics, UWA, Australia


– Member of Iranian medical council
– Member of Iranian Dental Association
– Member of Iranian association of Endodontists (IAE)
– Member of Australian Dental Association (ADA)
– Member of Australian Society of Endodontology (ASE)
– Member of American Association of Endodontists (AAE)
– Member of International Association of Dental Traumatology(IADT)
– Member of Royal Australasian College of Dental Surgeons (RACDS) in Specialist Practice of Endodontics.