To save time when you come in for your first visit, please fill in this form which will answer all the basic details we need to assist you further. This will help us and help you, saving time on both sides and making sure your needs are met.

When you arrive at the Centre, you simply sign the form containing all the responses you have provided here.

Personal Details

Surname

Given Name

Preferred Name

Title MrMrsMissMsDr

Home Address

Postcode    Date of Birth   Health Fund

Occupation

Phone No's:

(h) (w)(m)

Your Email (required)

Would you prefer to be contacted by LetterPhoneEmail

Whom may we thank for your referral to this office ?

 

Medical History

(please choose yes or no)

Rheumatic fever Chronic fatigue
Heart disorder Blood pressure
Pacemaker / Cardiac surgery Bleeding disorders
Thyroid disorder Epilepsy
AIDS/HIV (related diseases) Asthma
Radiotherapy Bronchitis
Chemotherapy Currently pregnant ?
Joint replacement Diabetes
Hepatitis B or C    

 

Do you have any allergies ? If so, please state:

Current medication:

Other Medical history:

Who is your medical practitioner ?

How long has it been since your last dental appointment?

Were any of these procedures performed on your teeth ?
ExaminedX-rayedCleaned

Dental History (please choose the symptoms that apply to you):

Teeth tender to chew onBleeding or discomfort of the gumsBad breathSpaces developing between teethChange of colour in teeth and/or gumsTeeth sensitive to hot, cold, sweetFood catching between teethSwelling or lump present in mouth Missing teeth (other than wisdom teeth)Regular clenching or grinding of teethFrequent headaches, neckaches or backacheClick or popping of TMJ (jaw joint)Tired jaws or teeth in the morningPain in the TMJ areaChewing only on one sideChange in appearance of the face

Do you use the following products ? How often ?

Toothbrush   Floss   Other

What concerns you the most about dental treatment?

Is there any improvement we could make to overcome this ?

What would help you enjoy your visit ? Please tick one or more of the following ?

AnaestheticNitrous Oxide (Happy) GasMusicFoxtel or MoviesAcupuncture

 

Financial Terms

  • Payment is expected at the time of your dental visit unless prior financial arrangements have been made with the dentist. Payment may be made by cash, cheque, Bankcard, Mastercard or Visa.
  • Failed appointments or failing to give 24 hours notice of a cancellation will incur a charge, the amount depending on the length of the appointment

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