Clinic Building

Read our practice newsletter for latest dental news...
Click here

Your Medical and Dental History

As a new patient we need to get to know you and your medical and dental history so that we can gain a comprehensive understanding of your current and past oral health to provide you with the highest quality treatment. For this reason we will request that you complete a New Patient Form. This can be done in just a few minutes at our practice, prior to your appointment.

However, for your convenience, we have also made this form available online, so the answers will be sent straight to our practice. Alternatively, you can also download to form to complete at a time that suits you.

Download from here.

Fax the completed forms to (02) 9251 1104.

Patient Information
Title:
Surname:* Given Name:*
Preferred Name: Date of Birth:*
Address:* Suburb:*
Postcode:*
Ph (home):* Mobile Number:
Ph (work):
E-mail:*
Vet Affairs Vet Affairs Card No:
VA Expiry Date:
Name of Private Health Fund (if any): Health Fund Card Number:
Position No on Card:
Occupation: Employer Name:
Next of Kin
Name: Relationship: Phone:

In case of an emergency whom should we contact?

Please indicate if different to next of kin.
Name: Relationship: Phone:
Reminder System

We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.
Medical History
How do you rate your general health?
Who is your General Practitioner?:
Telephone:

When was your last:

How frequently do you:
1. Dental Visit: 1. Brush:
2. Set of Dental X-Rays: 2. Floss:
3. Professional Cleaning: 3. See your dentist:

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

Have you ever had:

Do you:
Details: Details:

Please tick if the following apply to you:

Have you had or are you suffering from any of these? (please tick)
:
Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify):
What medications including natural remedies are you taking?:
Do you feel Nervous when having dental treatment?
I consent to having full mouth photos and x-rays to allow for correct diagnosis of my condition
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.
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.

 

Any surgical or invasive procedure carries risks. Before proceeding with a surgical or invasive procedure, you should seek a second opinion from an appropriately qualified health practitioner.
Web Design Sydney - Quantum Web Solutions