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New Patient Form
PERSONAL DETAILS
Please complete the following questionnaire:
Title
Dr
Mr
Mrs
Ms
Miss
Please select the preferred contact number above
Do you have Private Health Insurance that covers:
Dental
Y
N
Private Hospital
Y
N
How did you find out about our practice?
Family Member
Friend / Associate
Driving past / saw signage
Local Directory
Yellow Pages
Google
Website
Radio
Other:
DENTAL INFORMATION
Where applicable, please select Yes [Y] or No [N]:
Have you ever had your teeth cleaned by a hygienist?
Y
N
Have you had your wisdom teeth removed?
Y
N
Have you ever had gum disease or bleeding gums?
Y
N
Have you ever had braces or any other
orthodontic treatments?
Y
N
Do you wear a night guard?
Y
N
Do you clench/grind your teeth?
Y
N
Are your teeth sensitive to hot/cold?
Y
N
Does floss tear in between or food
get caught in your teeth?
Y
N
When was your last dental appointment?
< 12 months
1-2 years
other
When were dental x-rays last taken?
Less than a year ago
Longer than a year ago
MEDICAL INFORMATION
Please select Yes [Y] or No [N] to the following questions:
Heart problems
Y
N
Blood pressure
Y
N
Circulatory problems
Y
N
Anaemia
Y
N
Blood / immune disorders
Y
N
Excessive bleeding
Y
N
Excessive bruising
Y
N
Latex allergy
Y
N
Rheumatic fever
Y
N
Artificial joints
Y
N
Osteoporosis
Y
N
Cancer history
Y
N
Radiation treatment
Y
N
Hepatitis A B C D E
Y
N
Liver problems
Y
N
Penicillin allergy
Y
N
Kidney problems
Y
N
Epilepsy
Y
N
Diabetes
Y
N
Sinus trouble
Y
N
Asthma
Y
N
Ulcers (stomach)
Y
N
Reflux
Y
N
Other allergies
Y
N
If yes, please specify:
Are you on any medications?
Y
N
If yes, please list below:
Do you carry any emergency medications with you?
Y
N
If yes, please list below:
Any hospitalisations in the past 2 years?
Y
N
If yes, please list below:
Any other medical conditions not listed above?
Y
N
If yes, please list below:
Do you currently smoke?
Y
N
Are you pregnant?
(Women only)
Y
N
If yes, what is your due date?
Are you under the care of a GP?
Y
N
Are you under the care of a Specialist?
Y
N
CONSENT FOR TREATMENT
By submitting this form, I hereby authorise the dentist or designated team to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide appropriate care. I agree to the use of anesthetics’, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand I can ask for a complete recital of any possible complications. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made. I authorise that this data may be reviewed by team members of the dental practice.
