Print
Add: 24c Macquarie St Belmont, NSW 2280 | P: (02) 4945 8999 | F: (02) 4945 8972 | E: click here
Add: 93 Maitland Rd Mayfield, NSW 2304 | P: (02) 4968 2303 | F: (02) 4967 2171 | E: click here
 

Your Medical and Dental History

As a new patient we need to get to know you and your medical and dental history so we can gain a comprehensive understanding of your current oral health as well as learn about previous conditions to provide you with the highest quality treatment. Therefore, we will request that you complete a New Patient Form. You can fill in the form online or alternatively complete it in a few minutes at our practice, prior to your appointment.

For your convenience, your online form will be sent straight to our practice once you completed it. Alternatively, you can also download to form to complete it at a time that suits you. Then, simply fax the completed form back to us or bring it to your appointment.

Click here for our privacy policy.

Download from here.

Please fax any completed forms to Belmont (02) 494 589 927.

Mayfield (02) 4968 2303

Patient Information
Title:
Surname:* Given Name:*
Preferred Name: Date of Birth:*
Address:* Suburb:*
Postcode:*
Ph (home):* Mobile Number:
Ph (work):
E-mail:*
Vet Affairs Vet Affairs Card No:
VA Expiry Date:
Name of Private Health Fund (if any): Position No on Card:
Occupation: Employer Name:
Next of Kin
Name: Relationship: Phone:

In case of an emergency whom should we contact?

Please indicate if different to next of kin.

Name: Relationship: Phone:
Reminder System

We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.

Dental History
How long is it since your last thorough dental examination?:
Please tick any dental concerns you have?
Medical History
How do you rate your general health?
Who is your General Practitioner?:
Telephone:

Have you had or are you suffering from any of these? (please tick)

:
Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify):
What medications including natural remedies are you taking?:
How did you hear about us?
Referral Source:    
Keep Informed Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
Captcha
Please enter code from image

Consent for Services

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.

 

Dentistry