New Patient Form

Select TitleSelectMrMrsMsMissMasterDrProf

First Name

Last Name

Date of Birth

Email

Occupation

Address

Suburb

Postcode

Mobile

Home Phone

Work Phone

Emergency Contact Name

Relationship to you

Phone

Please complete this section only if you are less than 18 years of age

Guardian Name

Guardian Phone Number

Do you have Dental Health Insurance?

How did you find out about us?SelectInternet or WebsiteYellow PagesPrivate Health Insurance CompanyPatient Referral or Word of MouthHealthcare Professional ReferralFlyerWebsiteOther Internet Search EngineNewspaper PublicationOther

GP Name

GP Phone

GP Practice Address

Are your teeth ever sensitive to hot or cold?YesNo

Do you grind or clench your teeth?YesNo

Do you use dental floss?YesNo

Would you like your teeth to be whiter?YesNo

Do you play contact sport?YesNo

If so, do you use a mouthguard?YesNo

When was your last visit to a dentist?

How often do you renew your toothbrush?SelectAfter 1 MonthsAfter 2 MonthsAfter 3 MonthsAfter 4 MonthsAfter 5 MonthsAfter 6 Months

Anything needs to change about your teeth?

Please describe your medical history?

Please list ALL your current medications, including over-the-counter and vitamins.

Allergies/ Adverse Drug Reactions.

What is the main reason for your visit today?

Does dental treatment make you nervous?SelectNoSlightlyModeratelyExtremely

Have you ever had or require the following for dental treatment?SelectInhalational Sedation (Nitrous Oxide/Penthrox gas)Intravenous SedationGeneral Anaesthesia

I consent to the performing of dental surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics as indicated and I will assume responsibility for the fees associated with those procedures.
I am aware that payment is required on the day of treatment.
To the best of knowledge, all the preceding answers are true and correct. If I ever have any changes in my health, or if my medications change, I will inform the dentist at the next appointment without fail.
I consent to being contacted via various methods by the practice for dental related matters.