New Patient Form

Title

Name

First

Last

Date of Birth

Mobile

Phone

Address

Suburb

Postcode

Email

Do you wish to recieve promotions?

Yes

No

Emergency Contact Name (Please provide Guardian if under 18)

First

Last

Emergency Contact Mobile

Do you have private insurance dental cover, if so which fund?

When was your last dental visit and x-rays?

Have you ever had cosmetic procedures such as wrinkle treatments or dermal fillers?

Do you have any allergies to any drugs, medicines or latex?

Yes

No

Do you or have you ever suffered from any of the following? If so, please elaborate in the space provided.

RHEUMATIC FEVER

Yes

No

HEART PROBLEMS

Yes

No

ANAEMIA

Yes

No

TUBERCULOSIS

Yes

No

HEART VALVE (PROSTHETIC)

Yes

No

DIABETES

Yes

No

TUMOUR HISTORY

Yes

No

CARDIAC PACEMAKER

Yes

No

ARTHRITIS

Yes

No

CHEMOTHERAPY

Yes

No

HEPATITIS A, B OR C

Yes

No

ASTHMA

Yes

No

RADIATION THERAPY

Yes

No

HIV/AIDS

Yes

No

EPILEPSY

Yes

No

HIGH BLOOD PRESSURE

Yes

No

KIDNEY DISEASE

Yes

No

SINUS PROBLEMS

Yes

No

LIVER DISEASE

Yes

No

BLEEDING DISORDERS

Yes

No

OSTEOPOROSIS

Yes

No

SMOKER

Yes

No

FITS OR SEIZURES

Yes

No

PROSTHETIC JOINTS

Yes

No

PREGNANT

Yes

No

OTHER MAJOR SURGERY OR CONDITIONS:

By submitting this form, I understand all accounts are to be paid on the day of treatment in full.

I agree

We endeavour to provide a service to meet all of your dental requirements, to assist us in this we ask you to please fill out the questionnaire below:

What is the main reason fro your visit today?

Are you happy with the appearance of your teeth/smile?

Yes

No

Please list any dental concerns you may have:

Please check any other of the following services or treatment options you may wish to discuss with your dentist:

Please speak to your dentist about any concerns you may have in regards to any available treatments. We are able to provide a written quote to you at the end of your initial consult.

CANCELLATION POLICY AND ACKNOWLEDGEMENT

Your appointment time is reserved for you. If you cancel or change your appointment without adequate notice or fail to attend, this prevents us from treating other patients who may require our services. I understand and agree to pay a $50 cancellation per half hour fee if 48 hours’ notice is not given and / or if I fail to attend my appointment.

I acknowledge the information on this form is true and accurate to the best of my knowledge. I understand it is my responsibility to report any changes in medical status or condition.

I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand all accounts are to be paid on the day of treatment in full.

(03) 8790 2500

370 Pound Rd

Where you come first

Our Location

Treatments