New patient form

If you or your child are visiting our clinic for the first time, please complete the form below and we will contact you to make an appointment.

First Name

Last Name

Date of birth

Your Address

Suburb/Town

Postcode

Home Phone

Work Phone

Mobile

Do you have Private Health Insurance with extras?

Yes

Fund Name

Policy Number

Reference Number

Is your child eligible for the Medicare Child Dental Benefits Schedule (CDBS)?

Yes

Medicare Number

Child Reference Number

Department of Veteran's Affairs Card Number (if applicable)

Medical History

To the best of your knowledge do you have or have you suffered from the following?
Please select all that apply

If pregnant how many weeks

Are you on blood thinners such as Warfarin or Aspirin

Yes

Other - Please provide details

Are you concerned with any of the following?

Allergies and Adverse Reactions

Do you have any allergies?

Yes

Do you have any adverse reaction to drugs?

Yes

If Yes, please state allergy /reaction

Do you smoke?

Yes

If yes, how many per day?

Do you drink alcohol regularly?

Yes

Do you/have you received treatment for jaw related problems?

Yes

Please state any major surgery you have had in last 5 years

Medicines

There are many medications that may have impact on your oral health or treatment plan for you. Please indicate any medications that you are taking or have taken recently (including natural therapies). Alternatively a list from your GP can be attached.

Medication Details

You may also optionally upload Medication Details (PDF)

Have you previously had Botox/Dysport Fillers?

Yes

If yes, when?

I agree to be responsible for all payment of fees and understand that payment is due at the time of service. Please tick.

Yes i do

Do you consent to receive appointment reminders via email SMS or phone?

Yes