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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

    Name:
    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 phWork phMobileLetter
    Referred By:
    Yellow PagesAnother patient/friendStreet SignOther
    Another patient/friend (Name):
    Other (Please specify):
    Do you have Health Insurance for dental treatment?
    YesNo
    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?
    YesNo
    Details:
    Have you been a patient in hospital during the past two years?
    YesNo
    Reason:
    Have you taken any medicine tablets, capsules or drugs during the past two years?
    YesNo
    Details:
    Have you experienced any allergies or unusual effects from: tablets, drugs, injections or anaesthetic?
    YesNo
    Details:
    Are you, or have you been, under the care of a doctor during the past two years?
    YesNo
    Reason:
    Do you smoke?
    YesNo
    If yes, how many cigarettes a day?
    Have you ever had or have any of the following? If so, please tick as appropriate
    Heart TroubleHigh Blood PressureAsthmaBronchitis/Chest ProblemsHepatitis – Type A, B or CArthritisDepressive IllnessOsteoporosisEpilepsySevere HeadachesKidney TroubleGastric ProblemsAnaemiaCold SoresDrug DependenceRheumatic FeverDiabetes
    Have you had any prosthetic surgery? If yes, when? (E.g. Heart Valve, Hip Replacement, Knee Replacement etc)
    YesNo
    Details:
    Women Only: Are you pregnant?
    YesNo
    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?
    YesNo
    Details:
    Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?
    YesNo
    Do you become anxious or uncomfortable when you are having dental treatment?
    YesNo

    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: