Please fill in this questionnaire with accuracy,as we would like to get to know you. All information will be treated with confidentiality.


Contact Details

First Name:Mr/Mrs/Ms/Dr (required)

Last Name:

Address: (required)

Suburb:

Postcode:

Home Phone: (required)

Mobile: (required)

Work Phone:

Occupation:

Employer name::

Your Email (required)

In case of emergency whom should we contact? Please indicate

Name: (required)

Relationship: (required)

Phone: (required)

Reminder system

We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact .
 SMS to Mobile Call Mobile Call Home Phone Email

Email Updates

Would you like to be kept informed with updates on what is new in the practice, discounted services and new dental techniques.
 Yes No

Patient X – rays:

Would you like to allow us to use your xrays/tooth images for ongoing patient education? Please note your name and/or any other personal details will remain undisclosed.
 Yes No

Important:

How did you hear about us?
 Online reviews Our Website Yellow pages Seniors Booklet SMILE.COM.AU

By Friend/ colleague :(so we can thank them please write their name:)

How long is it since your last thorough dental examination?

Purpose of your appointment today

Medical History

Who is your Doctor/ General Practitioner?

Telephone:

Have you ever had or are you suffering from any of the below:(please tick)
 Heart Trouble High / low Blood Pressure Diabetes Hepatitis Osteoporosis Asthma HIV/AIDS Prosthetic implant/joint replacement Rheumatic Fever Are you or could you be pregnant Sleep Apnoea Allergies

What medications including natural remedies are you taking?

Do you want to discuss any of the following?(please tick)
 Dental implants Crowns or Veneers Invisalign/Braces Whitening or Bleaching Wisdom Teeth or other surgery Snoring or Breathing Disorder Root Canal Therapy

Patient Signature (required)

Date:

Security Check
captcha

*Please type the characters displayed above