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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: