New Patient Details

 

Please complete the form below

Name *
Name
Address *
Address
Date of Birth *
Date of Birth
If you ever change Health Funds, please let one of our friendly staff know.
Emergency Contact *
Emergency Contact
How did you find us? *
Choose as many that apply
Confidential Medical History - Please confirm details as relevant and leave other fields blank
Lifestyle
High Sugar
Lots of fizzy/acidic drinks
Recreational Drugs
Pregnancy or possibly pregnant
Heart
Choose as many that apply:
Blood
Choose as many that apply:
Alergies
Choose as many that apply:
Warnings
Choose as many that apply:
Chest
Choose as many that apply:
Other Conditions
Choose as many that apply:
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. *
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.
I accept the above conditions *
Current Date *
Current Date
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.