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New Patient Questionnaire

If you are a new patient please completed the below form and submit it to us.

Download PDF Form


PERSONAL DETAILS

Surname: 
 
First Names:
Dr / Mr / Mrs / Miss / Ms  
Preferred Name:
 
Address:
 
Postcode:
Home Phone:
Mobile:
 
Work Phone:
Occupation:
Date Of Birth:
E-mail:

How would you like to be contacted to notify you are due for a check up and clean?


Please tick appropriate:
 Home ph  Work ph  Mobile  Letter
Referred By:
 Yellow Pages  Another patient/friend  Street Sign  Other
Another patient/friend (Name):
Other (Please specify):
Do you have Health Insurance for dental treatment?
 Yes  No
Name of Fund:

Details of person to contact in an emergency:


Name:
Phone Number:
Medical Doctors Name:
Phone (If known):

MEDICAL HISTORY (if Yes, please give details)


Are you receiving any medical treatment at the present time?
 Yes  No
Details:
Have you been a patient in hospital during the past two years?
 Yes  No
Reason:
Have you taken any medicine tablets, capsules or drugs during the past two years?
 Yes  No
Details:
Have you experienced any allergies or unusual effects from: tablets, drugs, injections or anaesthetic?
 Yes  No
Details:
Are you, or have you been, under the care of a doctor during the past two years?
 Yes  No
Reason:
Do you smoke?
 Yes  No
If yes, how many cigarettes a day?
Have you ever had or have any of the following? If so, please tick as appropriate
 Heart Trouble  High Blood Pressure  Asthma  Bronchitis/Chest Problems  Hepatitis – Type A, B or C  Arthritis  Depressive Illness  Osteoporosis  Epilepsy  Severe Headaches  Kidney Trouble  Gastric Problems  Anaemia  Cold Sores  Drug Dependence  Rheumatic Fever  Diabetes
Have you had any prosthetic surgery? If yes, when? (E.g. Heart Valve, Hip Replacement, Knee Replacement etc)
 Yes  No
Details:
Women Only: Are you pregnant?
 Yes  No
If so, how many months:

DENTAL HISTORY


Name of Last Dentist:
(if you wish your records to be transferred over please let us know)
Approximate date of last dental visit: Details:
Do you have Dental pain or a Dental problem at present?
 Yes  No
Details:
Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?
 Yes  No
Do you become anxious or uncomfortable when you are having dental treatment?
 Yes  No

I acknowledge that I am responsible for all costs of treatment incurred. Payment for treatment is due on the day of treatment.

Signed: Patient/Parent/Guardian
_____________________________________________________________________
Date:
_____________________________________________________________________

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