New Patient Form

(This information may affect your dental treatment and will be treated in strictest confidence)

Name:


Address:

Phone:

How would you rate your health?

Are you being treated by a doctor (GP) at present?
 Yes No
Doctor’s name, address and telephone number & reason(s):
 Are you taking any medications or drugs at present (e.g. aspirin, contraceptive, etc)?
 Yes No
If yes, please list name(s) & reason(s):

 

 
Have you been in hospital in the past 12 months?
 Yes No
If yes, please list reason(s):
 Have you ever had any kind of surgery?
 Yes No
If yes, please list type:

 

 
Are you a smoker?
 Yes No
If yes, are you interested in ceasing smoking?
 Yes No		 (Females) Are you pregnant?
 Yes No
If yes, due date:

 

 
How would you rate your dental health?
 How long is it since your last visit to the dentist?

 

 
Are you having any dental/mouth pain or discomfort at present?
 Yes No 		Do your gums bleed when brushing your teeth?
 Yes No

 

 
Are you interested in whiter teeth?
 Yes No

Please tick any past or present illnesses

Other:
 Use the space below for additional details and other illnesses

 

 
Are you dentally covered by a health fund?
 Yes No		 Health fund:
No. on card (i.e. 01, 1, 02):
 Member ID:

My preferred payment method:

Emergency Contact:

Name:
 Home Tel:
 Mobile:
How did you hear about us?
 Referral by friends:
Name of friend:

Other:


Please leave this field empty.

I understand that my dental insurance carrier may pay less than the total bill for services. I agree to be responsible for
payment of all services rendered on my behalf or on behalf of my dependents at each appointment.