New Patient Details

Please complete the form below

Title

Name

First Name

Last Name

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Phone Number

Other Phone Number

Name of Person Responsible for Fees

Relation

Health Fund

If you ever change Health Funds, please let one of our friendly staff know.

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

Medical Doctor

Medical Doctor Phone Number

How did you find us?

Choose as many that apply

Website

Google

Facebook

Walkin

Maps

Friend

Other

If refered by family or friend, please ad their name

Confidential Medical History - Please confirm details as relevant and leave other fields blank

Lifestyle

Smokes (Per day)

High Sugar

Yes

Chew Tobacco (per day)

Lots of fizzy/acidic drinks

Yes

Alcohol (units per week)

Recreational Drugs

Yes

Pregnancy or possibly pregnant

Yes

If pregnant, please confirm how many weeks

Other details about lifestyle factors

Heart

Choose as many that apply:

Rheumatic Fever

High or Low blood pressure

Heart Surgery

Pacemaker Fitted

Heart Murmur

Angia

Thrombosis

Other details about heart conditions

Blood

Choose as many that apply:

Hepatitis A, B, C, or D

H.I.V / AIDS

Abnormal Blood Test

Blood refused by transfusion service

Anemia

Sickle Cell

Hemophilia

Other Details about blood condition

Alergies

Other Allergy Conditions

Warnings

Choose as many that apply:

Hearing/Sight Impairment

Antibiotic Cover required

Bruising or persistent bleeding

Currently under treatment

Do not recline

Steroids within two years

Warning card

Treatment requiring hospital

Other details about health warnings

Chest

Choose as many that apply:

Bronchitis

Cystic fibrosis

Pleurisy

Asthmatic

Emphysema

Pneumonia

Chest Surgery

Other Chest Conditions

Other Conditions

Other details about conditions

Medications

Consent

I have completed this questionnaire to the best of my knowledge, and understand that failure to make a full disclosure made place ME at undue medical 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 apointment and preventative care recall reminders. Please sign your name below.

First Name

Last Name

I accept the above conditions

I accept

Current Date

MM

DD

YYYY

On future visits any changes to the above should be advised. At any stage if have changed healthfunds or are planning to claim through one of the following schemes: Verteran Affairs, Medical Child Dental Scheme, Department or Human services - Emergency Dental Scheme or General Dental Scheme, please let one of our friendly staff members know.