NEw Patient Form

Before your first visit we ask that your fill in our Medical and Dental History form below. Alternatively please download the form here and bring this with you to your appointment.

Should you need to transfer your records from a different practice, please download the Record Release Form here.

Patient Information
Title Other:
Surname:* Given Name:*
D.O.B:*
Residential address:* Suburb:*
State: Postcode:*
Postal address (if different):
Home phone: Work phone:
Mobile:*
E-mail:*

We will send you email communications from time to time, including appointment reminders and our regular newsletter. Please tick the box below if you don’t wish to receive communication from us.

Occupation: Company:
Emergency contact: Phone:
Relation:
Private health insurer: Member #:
Patient #:
Medicare #: Ref #:
Expiry: Vets Affairs #:
Expiry:
GP name: GP phone:
GP address:
Preferred method of communication
Medical history

Please tick if you have ever had any of the following:

Blood disorder name:
Other condition:
Are you pregnant?
If yes, how many months?:
Are you Aboriginal or Torres Strait Islander?

Are you taking medication (including natural supplements)?

If yes, please list: :
Are you a smoker?
If yes, how often?:

Allergies

Other (please specify):
Dental history
Last dental visit::
Is there a particular reason for your visit today?:
Have you ever had a reaction or complication following dental treatment in the past?
If yes, please detail:
Is there anything else the dentist or hygienist should be aware of?:

Do you generally feel anxious about seeing your dentist and/or hygienist?

Are you suffering from any of the following?

Have you ever had a sleep study and been diagnosed with sleep apnoea?
If yes, have you ever tried Continuous Positive Airway Pressure (CPAP) therapy?
Has anyone ever told you that you snore?
After 6-7 hours of sleep do you wake up refreshed?
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.