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

Following the Victorian government stage 4 lockdowns and the guidelines outlined by the Australian Dental Association, from 6th August 2020, we are only seeing patients for emergencies and those that require urgent care. These restrictions will be in place for the next 6 weeks. Please check our website for updates on when normal services will resume. Thank you for your continued support and stay safe.

SMDG team