265 Park Street South Melbourne

Victoria 3205 Australia

T 61 3 9690 6388 – F 61 3 9699 8182

info@southmelbournedental.com.au

Monday to Thursday 9.00 am – 6.00 pm

Friday 9.00 am – 5.00 pm

Saturday 9.00 am – 1.00 pm

265 Park Street South Melbourne

Victoria 3205 Australia

T 61 3 9690 6388 – F 61 3 9699 8182

info@southmelbournedental.com.au

Monday to Thursday 9.00 am – 6.00 pm

Friday 9.00 am – 5.00 pm

Saturday 9.00 am – 1.00 pm

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

Step 1 of 3

  • Patient details
  • First name
  • Surname
  • Title (e.g. Mr/Mrs/Other)
  • Date of birth (DD/MM/YYYY)

  • Address
  • Suburb
  • Postcode
  • Phone
  • Mobile
  • Email
  • Fax

  • Name of person responsible for fees
  • Relationship

  • Emergency contact
  • Relationship
  • Phone

  • Medical doctor
  • Address
  • Suburb
  • Postcode

19/02/2021

We are back to seeing regular patients. We will require all patients to wear masks on entry and whilst walking around inside the clinic.  If you are exhibiting cold and flu-like symptoms, please call 9690 6388 to reschedule your appointment. Thank you. We looking forward to seeing you

SMDG