New Patient Form New Patient Form Title * Mr Mrs Miss Dr Name * Name First First Last Last Date of Birth * Mobile * Phone Address * Suburb * Postcode * Email * Do you wish to recieve promotions? * Yes NoEmergency Contact Name (Please provide Guardian if under 18) Emergency Contact Name (Please provide Guardian if under 18) First First Last Last Emergency Contact Mobile * Do you have private insurance dental cover, if so which fund? * When was your last dental visit and x-rays? * Have you ever had cosmetic procedures such as wrinkle treatments or dermal fillers? * Do you have any allergies to any drugs, medicines or latex? * Yes NoDo you or have you ever suffered from any of the following? If so, please elaborate in the space provided.RHEUMATIC FEVER * Yes NoHEART PROBLEMS * Yes NoANAEMIA * Yes NoTUBERCULOSIS * Yes NoHEART VALVE (PROSTHETIC) * Yes NoDIABETES * Yes NoTUMOUR HISTORY * Yes NoCARDIAC PACEMAKER * Yes NoARTHRITIS * Yes NoCHEMOTHERAPY * Yes NoHEPATITIS A, B OR C * Yes NoASTHMA * Yes NoRADIATION THERAPY * Yes NoHIV/AIDS * Yes NoEPILEPSY * Yes NoHIGH BLOOD PRESSURE * Yes NoKIDNEY DISEASE * Yes NoSINUS PROBLEMS * Yes NoLIVER DISEASE * Yes NoBLEEDING DISORDERS * Yes NoOSTEOPOROSIS * Yes NoSMOKER * Yes NoFITS OR SEIZURES * Yes NoPROSTHETIC JOINTS * Yes NoPREGNANT * Yes No OTHER MAJOR SURGERY OR CONDITIONS: By submitting this form, I understand all accounts are to be paid on the day of treatment in full. * I agreeWe endeavour to provide a service to meet all of your dental requirements, to assist us in this we ask you to please fill out the questionnaire below: What is the main reason fro your visit today? Are you happy with the appearance of your teeth/smile? Yes No Please list any dental concerns you may have: Please check any other of the following services or treatment options you may wish to discuss with your dentist: Teeth whitening Orthodontics or straightening of the teeth Cosmetic treatment to enhance your smile Replacing missing teeth Preventative dentistry Financing options/Payment plans Dentistry under sedationPlease speak to your dentist about any concerns you may have in regards to any available treatments. We are able to provide a written quote to you at the end of your initial consult.CANCELLATION POLICY AND ACKNOWLEDGEMENT * Your appointment time is reserved for you. If you cancel or change your appointment without adequate notice or fail to attend, this prevents us from treating other patients who may require our services. I understand and agree to pay a $50 cancellation per half hour fee if 48 hours’ notice is not given and / or if I fail to attend my appointment. I acknowledge the information on this form is true and accurate to the best of my knowledge. I understand it is my responsibility to report any changes in medical status or condition. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand all accounts are to be paid on the day of treatment in full. If you are human, leave this field blank. Submit
