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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
Update your details
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Please Enter Your Details Below
*Surname
*First Name
*Date Of Birth
*Street 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
Confidential Medical History
Are you or have you ever been treated for any of the following?
.
Rheumatic Fever
.
Diabetes Type 1/2
.
Blood Disorder
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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
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.
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