If you are a new patient please completed the below form and submit it to us.
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Dr / Mr / Mrs / Miss / Ms
Date Of Birth:
Please tick appropriate:
Home phWork phMobileLetter
Yellow PagesAnother patient/friendStreet SignOther
Another patient/friend (Name):
Other (Please specify):
Do you have Health Insurance for dental treatment?
Name of Fund:
Medical Doctors Name:
Phone (If known):
Are you receiving any medical treatment at the present time?
Have you been a patient in hospital during the past two years?
Have you taken any medicine tablets, capsules or drugs during the past two years?
Have you experienced any allergies or unusual effects from: tablets, drugs, injections or anaesthetic?
Are you, or have you been, under the care of a doctor during the past two years?
Do you smoke?
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)
Women Only: Are you pregnant?
If so, how many months:
Name of Last Dentist:
(if you wish your records to be transferred over please let us know)
Approximate date of last dental visit:
Do you have Dental pain or a Dental problem at present?
Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?
Do you become anxious or uncomfortable when you are having dental treatment?
I acknowledge that I am responsible for all costs of treatment incurred. Payment for treatment is due on the day of treatment.