Contact Us
  • (07) 4787 8701
  • Open from Monday - Friday at 8am to 5pm, Saturdays on appointment only.
  • New Patient Form

    It is important to know details about your medical history as these could affect the success of your dental
    treatment and how we can provide this treatment safely for you. The information you provide is confidential and
    will be handled in accordance with our privacy policy which is shown in the last section of this form.

    Please tick the box you most agree with to help us in completing our survey.

      Personal Detail
    First Name*
    Middle Name
    Surname*
    Date of Birth*
    Phone Number*
    Occupation
    Mobile Number*
    Home Address*
    Email Address

    Health Fund
    Member Number
    Emergency Contact Name*
    Their Contact No*.

    To complete only if the patient is under 18 years old

    Guardian Name
    Contact Number
    Address

    Referral Information








    Other
      Medical History
    Name of your GP
    Your Doctor's Phone No.
    Your Doctor's address

    Have you ever had any of the following? Please tick those that apply:

    Anaemia

    Artificial joints

    Asthma

    Blood Disease

    Cancer

    Dizziness

    Epilepsy

    Excessive Bleeding

    Diabetes

    Fainting

    Glaucoma

    Heart Disease

    Heart Murmur

    Hepatitis A, B, C

    Jaundice

    Kidney Disease

    Liver Disease

    HIV/ AIDS

    Pacemaker

    Radiation Therapy

    Respiratory problems

    Rheumatic fever

    Sinus problems

    Stroke

    Tuberculosis

    Tumours

    Psychological Disorders

    Do you normally require antibiotic cover before dental treatment?




    Are you pregnant?




    If yes, how many months?
    Have you had any serious illnesses in the last 2 years?




    If yes, please provide more information
    Do you have any allergies to Penicillin or other drugs?




    If yes, please provide more information
    Do you suffer from sleep apnoea?




    Is your blood pressure




    Do you smoke? If so how many per day?




     
    Have you had any abnormal reactions to local or general anaesthesia?




    Please list any other known allergies (including latex, foods and preservatives)
    Are you taking any prescription or other medications at present?




    Please list current medications
      Dental History

    Are you concerned about or experiencing any of the following dental problems?
    (please tick if applicable)

    Bad breath

    Bleeding gums

    Clicking/pain in the jaw joints

    Discoloured fillings

    Food trapping between your teeth

    Grinding or clenching of your teeth

    Head/neck ache

    Roughness of existing fillings

    Sensitivity to hot or cold

    Sensitivity when eating

    Staining of your teeth

    Other... Please describe below

    Are you concerned with: (please tick if applicable)

    Ability to eat

    Crooked teeth or Missing teeth

    Discolouration of your teeth

    Existing crowns, bridges or dentures

    Gaps between your teeth

    Previous dental treatment

    Silver fillings

    Tooth clean techniques (e.g. Brushing)

    Your smile

    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?




    Gas (Nitrous oxide-laughing gas)

    General Anaesthesia

    Intravenous sedation

      Consent for Services
    • I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or
      advisable, including the use of local anaesthetics as indicated and I will assume responsibility for the fees
      associated with those procedures.
    • I understand that the practice requires at least 24 hours notice if I need to cancel my scheduled appointment and
      that a cancellation fee of $50.00 could be incurred if I fail to do so.
    • I hereby consent to the use of any study models, x-rays, computer images and photographs at various dental
      seminars, lectures, and publications that the dentists may author.
    • I am aware that payment is required on the day of treatment.
    • We provide as a courtesy to our patients a preventative recall program that offers a call service if you have not
      been to the practice in 6 months. Do you wish to receive a phone call from the practice in the event that you have
      missed your recall?
    • Yes I agree

    Privacy Policy

    • This information will only be used by the treating dentist in order to deliver your care to the highest standards.
    • It will not be disclosed to those not associated with your treatment without your consent except as provided under the
      legislation and where we consider you would have a reasonable expectation of us to provide such information.
    • You may seek access to the information held about you and we will provide this access without undue delay.
      This access might be by inspection of your dental records at the time of appointment or by special access or
      copying of information at other times.
    • There will be no charge made for requesting this information but there may be fees levied just to cover the costs
      associated with the processing of this request or the copying of information.
    • We will take reasonable steps to protect this information from misuse or loss and from unauthorised access,
      modification or disclosure.
    • Our staff are trained to respect these principles at all times.

  • Open from Monday - Friday at 8am to 5pm, Saturdays on appointment only.
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