Please fill out all the necessary information on this form and click on SUBMIT FORM at the bottom of the page; when you sign the bottom of this page you agree that you are happy for your information to be used by any dentist/staff member in accordance with your treatment.

Title: First name: Surname:

D.O.B: Mobile: Phone:

Address: Suburb: Postcode

Email: Please tick box if you do not wish to receive promotions

Emergency/secondary contact name and number (Please provide Guardian if under 18):

Referral Source?

Do you have private insurance with dental cover, if so which fund?

When was your last dental visit and x-rays?

Do you have allergies to any drugs, medicines or latex? If yes

Please state ALL medications you are currently taking including bisphosphonates or blood thinners:

Do you or have you ever suffered from any of the following? If so, please elaborate in the space provided.

RHEUMATIC FEVER

HEART PROBLEMS

ANAEMIA

TUBERCULOSIS

HEART VALVE (PROSTHETIC)

DIABETES

TUMOUR HISTORY

CARDIAC PACEMAKER

ARTHRITIS

CHEMOTHERAPY

HEPATITIS A, B OR C

ASTHMA

RADIATION THERAPY

HIV/AIDS

EPILEPSY

HIGH BLOOD PRESSURE

KIDNEY DISEASE

OTHER MAJOR SURGERY OR CONDITIONS:

SINUS PROBLEMS

LIVER DISEASE

BLEEDING DISORDERS

OSTEOPOROSIS

SMOKER

FITS OR SEIZURES

PROSTHETIC JOINTS

PREGNANT

BY SIGNING THIS FORM, I UNDERSTAND ALL ACCOUNTS ARE TO BE PAID ON THE DAY OF TREATMENT IN FULL

I confirm that when attending the clinic I will ensure I have no symptoms of Covid-19 and have not been in contact with anyone with Covid-19 and consent to a temperature check onsite.

Signed: Date:

We endeavour to provide a service to meet all of your dental requirements, to assist us in this we ask you to please fill out the questionnaire below:

What is the main reason for your visit today?

Are you happy with the appearance of your teeth/smile?

Please list any dental concerns you may have :

Please click any other of the following services or treatment options you may wish to discuss with your dentist:

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Please speak to your dentist about any concerns you may have in regards to any available treatments. We are able to provide a written quote to you at the end of your initial consult.