Online Patient Form

Contact Information

Name*

Prefix First Middle Last

Preferred Name (if any)

Date Of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Other Contacts

Emergency Contact Name*

Emergency Contact Phone*

Are you a member of a private health fund? If yes please state*

Complete this only if the patient is under 18 years of age

Guardian Name

Guardian Phone

Guardian Address

Medical History

Name Of GP*

Doctor's Phone*

Doctor's Address*

Have you ever had any of the following?

Are you pregnant, and if so how many months?

Have you had any serious illnesses in the last 2 years?

If yes, please provide more information.

Are you currently taking any medications or tablets regularly?

If yes, please provide the name of the medication.

Do you take any tablets or injections that affect your bones?

If yes, please provide the name of the medication.

Do you have any allergies to Penicillin or other drugs?

If yes, please provide the name of the medications you are allergic to.

Do you suffer from sleep apnoea?*

Is your blood pressure normal, high or low?*

Do you smoke?*

If so how many per day?

Dental History

Are you concerned about or experiencing any of the following dental problems?

Please tick as many as it applies

Are you concerned with

Ability to eat your smile
Silver fillings
Gaps between your teeth
Discolouration of your teeth
Previous dental treatment
Existing crowns, bridges or dentures
Crooked teeth
Tooth cleaning techniques (e.g. brushing & flossing)
Missing teeth

Please tick as many as it applies

What is the main purpose of your visit today?*

How long since your last dental visit?*

Does dental treatment make you nervous?

Have you ever had or require the following for dental treatment?

Do you grant permission for your case to be used for continuing dental education & lecturing?

How did you hear about us?*

Google
Yellow Pages
Referred by doctor / dentist
Friend or Family
Website
Other

Todays Date

Monday - Friday	8 am-5pm
Saturday	8am - 12pm

The latest news

Online New Patient Form

Contact Information

Other Contacts

Complete this only if the patient is under 18 years of age

Medical History

Dental History

For more information or to arrange an appointment, contact us today!

Practice Information

Opening Hours

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