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Menu
Home
New Patients
Patient forms
New Patient Form
Update Your Details
Services
Our Team
Health Funds
Contact Us
Home
New Patients
Patient forms
New Patient Form
Update Your Details
Services
Our Team
Health Funds
Contact Us
Menu
Home
New Patients
Patient forms
New Patient Form
Update Your Details
Services
Our Team
Health Funds
Contact Us
New Patient Form
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Please Enter Your Details Below
*Surname
*First Name
*Date Of Birth
*Address
*Suburb
*Postcode
Preferred Contact Number
.
Home Phone
.
Business Phone
.
Mobile Phone
Home Phone
Business / Work Phone
Mobile Phone
*Email
Employer
Occupation
Next of Kin Information
Next of Kin
Relation of Your Next of Kin
Next of Kin Phone Number
Do you have Private Health Cover for Dental:
.
Yes
.
No
Name of Health Fund
Person Responsible For This Account
Who Referred You To Our Practice
Confidential Medical History
Are you or have you ever been treated for any of the following?
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Rheumatic Fever
.
Diabetes Type 1/2
.
Blood Disorder
.
HIV/Hepatitis A B C
.
Kidney disease
.
Asthma
.
Nervous Disorders
.
Epilepsy
.
Malaria
.
Angina
.
A stroke
.
High/Low Blood Pressure
.
High/Low Cholesterol
Have You Been Treated For Cancer?
.
Yes
.
No
Year Of Cancer Treatment?
Do You Smoke?
.
Yes
.
No
If So How Many Per Day?
Allergies
Do You Have Any Drug Allergies?
.
Yes
.
No
Latex Allergy?
.
Yes
.
No
Other Allegies (Please List)
Are You Taking Any Medications?
.
Yes
.
No
If Yes, Please List
Are You Recieving Any Medical Treatments?
.
Yes
.
No
If Yes, Please List
Have you had an unfavourable reaction to local anaesthetics?
.
Yes
.
No
Name Of Medical Practitioner
Phone Of Medical Practitioner
Pregnancy
Are You, or is there any possibility that you are pregnant?
.
Yes
.
No
Due Date
When was your last dental visit?
Have you had any problems with previous dental visits?
.
Yes
.
No
If yes, what is your previous experience?
Do you feel that you grind your teeth?
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Yes
.
No
Does your jaw click?
.
Yes
.
No
Do you wake with a sore/tired jaw?
.
Yes
.
No
Have you ever been prescribed a “night guard”?
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Yes
.
No
How often do you brush your teeth?
.
Once A Day
.
Twice A Day
.
Three Times A Day
Which type of toothbrush do you use?
.
Manual
.
Electric
Do your gums bleed when you clean your teeth?
.
Yes
.
No
Do you floss?
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Everyday
.
Sometimes
.
Never
Have you ever been diagnosed with Periodontal Disease?
.
Yes
.
No
Have you ever had your gums treated by a Dental Hygienist?
.
Yes
.
No
Do you have worn, uneven edges on your teeth?
.
Yes
.
No
If yes, do these bother you ?
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Yes
.
No
Do you have chips on your teeth that bother you?
.
Yes
.
No
Do you have spaces that bother you?
.
Yes
.
No
Do you like the colour of your teeth?
.
Yes
.
No
How would you improve your smile?
.
Colour
.
Add length
.
Add width
.
Shape
Send New Patient Form
We request and expect payment at the time of treatment.
For your convenience Design Dental Group is equipped with the "HICAPS" system and accept cash, cheques, eftpos,
and most major credit cards.
