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(07) 4051 4580
Ground Floor "Accent on McLeod"
93-95 McLeod St
Cairns
QLD
4870
Home
Our Treatments
Preventive
Lip and Tongue Tie
Tongue and Lip Tie Guide
Dental Hygiene
Dental Hygiene Products
Amalgam Replacement
Children’s Dentistry – CDBS
Mouthguards
Air Abrasion
Laser Dentistry
Dysfunctional Breathing
Fluoride Treatment
Restorative
Crowns
Bridges
Dental Implants
Over Dentures
Dentures
Inlays and Onlays
Root Canal
Full Mouth Reconstruction
Orofacial Pain
TMJ Pain
Occlusal Splint Therapy
Occlusal Therapy & Migraine Treatment
Therapeutic Injectables
Neuropathic Pain
Medical
Oral Cancer Screening
Dry Mouth – Xerostomia
Bad Breath – Halitosis
Snoring & Sleep Apnoea
Investigation of Obstructive Sleep Apnoea
Nose score in snoring & OSA Assessment
Oventus O2Vent Optima
Myofunctional Therapy in OSA for Patients Handout
Tongue Exercises
Cosmetic
Porcelain Veneers
Teeth Whitening
Aesthetic Composite Bonding
Tooth Contouring
Gum Lifts
Digital Smile Design
Orthodontics
ClearCorrect
About Us
Our Team
Dr Bob Gibbins, BDSC (HONS) QLD
Patient Referrals
Finance Options
Smile Right
Patient Centre
Smile Gallery
Medical History Form
Injectables History Form
Patient Appreciation Program
Media Centre
Contact Us
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Injectables History Form
Injectables History Form
Name
*
First
Last
Date
DD slash MM slash YYYY
Postal Address / P.O Box
*
Street Address
Address Line 2
City
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
State
Post Code
Home Phone
*
Mobile Phone
*
Work Phone
*
Email Address
*
Occupation
Whom may we thank for referring you to our practice?
How did you find us?
*
Our website
Friend
Doctor
Television advertising
Business card
White pages
Yellow pages
Radio advertising
PDC directory
Newspaper
Directory
Other
Please list the main reasons for seeking care today:
*
The name of your private health fund:
Emergency contact:
*
Relation to emergency contact:
Husband
Wife
Partner
Mother
Father
Other
Emergency contact phone number:
Name of your doctor:
Doctor's Address:
Doctor's Phone:
Is another family member a patient at our office?
Yes
No
You may wonder the relevance of our asking the following medical questions. Due to the high percentage of the population now who have had, or who are contemplating having anti-wrinkle treatments, dermal fillers, and muscle relaxant therapy for migraines, tension-type headaches, temper-mandibular disorders, fibromyalgia, or myofascial pain dysfunction, it is necessary to ask these confidential medical questions to protect your health.
Have you ever had Botulinum Toxin treatments including Botox, Dysport or xeomin for any reasons at all?
Yes
No
Have you ever had Cosmetic treatment using Dermal Fillers like Restylane, Juvaderm, Esthelis, Modelis, Fortelis, Teosyal, Sculptra, Radiesse, CPM or Swedish Dermal Filler or others?
Yes
No
Do you have any known sensitivity to Botulin Toxin A or B, Albumin (eg. In egg white), Sodium Chloride, Lactose or Milk Proteins?
Yes
No
Do you have any known neuro-muscular conditions or auto-immune conditions such as Myasthenia Gravis, Eaton Lambert Sydrome or Multiple Sclerosis?
Yes
No
Do you have any Peripheral Motor Neuropathic Disease or Muscle Weakness such as Amyotrophic Lateral Sclerosis Lou Gehrig’s Disease?
Yes
No
Are you or have you recently taken Aminoglycosides Antibiotic including Clindamycin, Gentamycin or Streptomycin?
Yes
No
Are you or have you recently taken any medicines such as relaxants or medicines that interfere with muscular transmission including Tubocurarine?
Yes
No
Are you or have you recently taken any Anti-Coagulant medicines like Aspirin, Warfarin, Heparin, Clexane, Rivaroxaban, Asasantin, Vitamin E or Omega-3 Fish Oil or others?
Yes
No
Have you ever had any reconstructive or cosmetic facial surgery to the facial region?
Yes
No
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Our Treatments
Preventive
Restorative
Orofacial Pain
Medical
Cosmetic
Orthodontics
Make an Enquiry
Contact Details
Phone
(07) 4051 4580
Fax
(07) 4031 5226
Email
info@futuredental.com.au
Address
Ground Floor "Accent on McLeod"
93-95 McLeod St
Cairns
QLD
4870
Hours
Monday
8:00am - 5:00pm
Tuesday
8:00am - 5:00pm
Wednesday
8:00am - 5:00pm
Thursday
8:00am - 5:00pm
Home
Our Treatments
Preventive
Lip and Tongue Tie
Tongue and Lip Tie Guide
Dental Hygiene
Dental Hygiene Products
Amalgam Replacement
Children’s Dentistry – CDBS
Mouthguards
Air Abrasion
Laser Dentistry
Dysfunctional Breathing
Fluoride Treatment
Restorative
Crowns
Bridges
Dental Implants
Over Dentures
Dentures
Inlays and Onlays
Root Canal
Full Mouth Reconstruction
Orofacial Pain
TMJ Pain
Occlusal Splint Therapy
Occlusal Therapy & Migraine Treatment
Therapeutic Injectables
Neuropathic Pain
Medical
Oral Cancer Screening
Dry Mouth – Xerostomia
Bad Breath – Halitosis
Snoring & Sleep Apnoea
Investigation of Obstructive Sleep Apnoea
Nose score in snoring & OSA Assessment
Oventus O2Vent Optima
Myofunctional Therapy in OSA for Patients Handout
Tongue Exercises
Cosmetic
Porcelain Veneers
Teeth Whitening
Aesthetic Composite Bonding
Tooth Contouring
Gum Lifts
Digital Smile Design
Orthodontics
ClearCorrect
About Us
Our Team
Dr Bob Gibbins, BDSC (HONS) QLD
Patient Referrals
Finance Options
Smile Right
Patient Centre
Smile Gallery
Medical History Form
Injectables History Form
Patient Appreciation Program
Media Centre
Contact Us
It is a requirement for all persons (including accompanying person/s) who enter Future Dental to scan the QR code and fill in a COVID screen.
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Did you know you’re at more risk of cracking teeth with those old silver “Amalgam” fillings? Talk to us about amalgam replacement!
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The wait is over!You don’t have to wait weeks for your crowns, talk to us about E4D crowns and One Visit Crowns
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Did you know? Untreated Obstructive Sleep Apnoea can increase risk of serious health problems like heart attack and stroke
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FACT - Dry mouth leaves you at risk of decay, and we can help with your dry mouth.
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Lip and Tongue Tie can affect your baby’s growth and development, come and see Dr Bob about how we can help.
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Did you know regular efficient flossing keeps not just your teeth, but your gums healthy too? Talk to us about Dental Hygiene
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FACT – sometimes migraines are caused by grinding your teeth! Talk to us about Occlusal Therapy and Migraine Treatment and Therapeutic Injectables
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Teeth Whitening has never been so easy! Ask us why.
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Straightening your teeth doesn’t have to mean braces, talk to us about ClearCorrect
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