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New Patient Form

Your medical and dental history

As a new patient we ask you to fill out a medical and dental health form while at the practice. However, for your convenience we have made it available online so you can simply fill it in and submit to us directly, cutting your time spent in the waiting room.

All the information is held in strict confidence and will be used to assist in your dental assessment and treatment planning.

Your dentist will then advise you of any potential problem areas, present you with all the necessary information and treatment options available and their experienced, professional recommendation. Then you can make an informed decision regarding any treatment you may have.

Upon completion of the form you will also receive a copy for your own records. Your copy will be sent to the email address you provide below.

Patient Information
Surname:* Given Name:*
Title: Preferred Name:
Occupation: Address:*
Date of Birth:*
Suburb:*
Postcode:* Preferred Contact Number:
Ph (home):* Mobile Number:
Ph (work):
E-mail:* Do you have private health cover?
Private Health Cover Provider:
Next of Kin

(To be completed only if the patient is under 18 years of age)

Guardian Name: Phone:
Address:
Medical History
Name of your General Practitioner:
Contact Number:
Address:
I have medical information that I do not wish to write down and would like to discuss with the dentist in private
Are you pregnant or think you may be? Are you allergic to penicillin?
Please list any other known allergies:

Have you a history of any of the following?

Blood Pressure:
If yes, how many per day?:
List current medications:
Dental History
Are you attending for a general check up? Do you have an immediate dental problem?

Are you concerned about or experiencing any of the following dental problems? Please tick all that apply.

Are you concerned with

Do you normally have injections for dental treatment?
How often do you brush your teeth?:
How often do you floss?: Does dental treatment make you nervous?
How long since your last dental visit?:*
Is there any other information you feel may be of value regarding your dental treatment?:
How did you hear about us?
Referral Source:    
Keep Informed Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
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Consent for Services

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.

 

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