New Patient Form

 

Be reassured that we use all patient information in complaince with State and Federal law. To view our full privacy policy, please click here

Patient Information
Title:
Surname:* First Name:*
Date of Birth:*
E-mail:* Who referred you to us?:
Address:* Suburb:*
Postcode:*
Ph (home):* Mobile Number:
Ph (work):
Emergency Contact: Phone:
General Medical Practitioner: Phone:
Medical History

Have you had or are you suffering from any of these? (please tick)

Any Other Condition:
Are you allergic to anything (such as penicillin or Latex)?:
Are you currently taking any pills, tablets or medications?:
Do You Smoke?
Are You Pregnant?
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.