If you are a new patient please completed the below form and submit it to us.
Download PDF Form
Name:
Surname:
First Names:
Dr / Mr / Mrs / Miss / Ms
Preferred Name:
Address:
Postcode:
Home Phone:
Mobile:
Work Phone:
Occupation:
Date Of Birth:
E-mail:
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:
Phone Number:
Medical Doctors Name:
Phone (If known):
Are you receiving any medical treatment at the present time?
Details:
Have you been a patient in hospital during the past two years?
Reason:
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: Details:
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.
Signed: Patient/Parent/Guardian
Date:
