Patient Information
Title:* Surname:*
Given Name:* Date of Birth:*

Address:* Suburb:
Postcode:*
Ph (home):* Mobile Number:
Ph (work): E-mail:*
Occupation: Private Health Fund?
Name of Private Health Fund?:
Next of Kin
Name:
Phone: Relationship:
Medical History

Have you had or are you suffering from any of these? (please tick)

Due Date:
Infectious Diseases? Specify:
Other Serious Illness? Specify:
Are you taking medication? If yes, please list.:
Who is your Medical Doctor?:
Phone:
Patient Allergies

Do you suffer from any of these allergies?

Other Allergies. Specify:
Please tick any dental concerns you have?
Other. Specify:
How did you hear about us?
Referral Source:    
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To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
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Consent for Services

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.

 

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