About us
Services
Team
What’s on
Privacy
Patients
New patient form
Review
Contact
Book online
About us
Services
Team
What’s on
Privacy
Patients
New patient form
Review
Contact
Book online
About us
Services
Team
What’s on
Privacy
Patients
New patient form
Review
Contact
Book online
About us
Services
Team
What’s on
Privacy
Patients
New patient form
Review
Contact
Book online
New patient form
If you prefer to fill the form offline,
click here
– don’t forget to print it out and bring it with you on your first appointment.
New patient form
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Patient details
First name
*
First name
Surname
*
Surname
Title (e.g. Mr/Mrs/Other)
Title (e.g. Mr/Mrs/Other)
Date of birth
*
Day
Month
Year
Date of birth (DD/MM/YYYY)
Are you of Aboriginal or Torres Strait Islander origin?
*
Yes
No
Prefer not to say
Address
*
Address
Suburb
*
Suburb
Postcode
*
Postcode
Phone
*
Phone
Mobile
Mobile
Email
Email
Fax
Fax
Name of person responsible for fees
Name of person responsible for fees
Relationship
Relationship
Emergency contact
Emergency contact
Relationship
Relationship
Phone
Phone
Medical doctor
Medical doctor
Address
Address
Suburb
Suburb
Postcode
Postcode
Medical details
Have you ever had any of the following? Please tick where relevant.
Health issues
High blood pressure
Heart ailment
Rheumatic fever
Asthma, chest or breathing problems
Tuberculosis
Diabetes
Stomach or bowel problems (e.g. ulcer)
Kidney disease
Thyroid problems
Excessive bleeding or blood disorder
Bone disorder (e.g. osteoporosis)
Hepatitis
Aids / HIV
Epilepsy
Female patients, are you pregnant?
Do you smoke?
Per day
Per day
List any previous illnesses
List any previous illnesses
Dental treatment, implants and allergies
Have you ever had any problems with dental treatment? (e.g. adrenaline intolerance)
Do you have an artificial hip, heart or prosthetic implant?
Do you have any allergies?
If yes please list (e.g. penicillin, latex)
If yes please list (e.g. penicillin, latex)
Medical care and drugs
Are you presently under medical care?
Are you taking any drugs, medicines or tablets?
If yes please list
If yes please list
Private health insurance
Do you have private health insurance?
Which fund?
Which fund?
How did you find out about us?
How did you find out about us?
I have completed this questionnaire to the best of my knowledge and understand that failure to make a full disclosure may place me at undue risk. I understand that notes, radiographs (x-rays) or models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this. I also give my permission for the practice to use the above contact details to send me appointment and check up reminders.
I understand that payment of accounts in full is required on the day and accept full liability for Healthcare fund claims which are rejected. In the event where an overdue account is referred to a collection agency or solicitors, I will be liable for all legal costs and commission arising.
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