New Patient Form

We know your time is valuable to you, so to help new patients (or existing patients who need to update their information), we offer our new patient form electronically.

Simply download the form at the link below and email it back to us. Or, you can print it out at home and bring it with you to your appointment. 

Click here to access our new patient form online.  

 

Patient Information
Title:
Surname:* Given Name:*
Preferred Name: Date of Birth:*
Address:* Suburb:*
Postcode:*
Ph (home):* Mobile Number:
Ph (work):
E-mail:* Occupation:
Family and emergency contact

Is another member of your family a patient at our clinic?

Please name:

Details for emergency contact (or parent/guardian)

Name: Phone:
Dental History
How long is it since your last thorough dental examination?:
Please tick any dental concerns you have?
Medical History
How do you rate your general health?
Who is your General Practitioner?:
Telephone:

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?:
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.