New Patient Form

In order to provide optimal dental care, in the safest possible way it is important to know a little about you.

Please fill out the form below, including any health problems which may affect your treatment. The information you provide remains strictly confidential.

This information will be kept on file for your first and continued visits.

A friendly reminder we require payment away every appointment and cheques are not accepted.

Please note: * means this is a required field


Personal Details

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How did you come to select this practice?





Medical History

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General Medical Information

Please select any of the following medical conditions you may have had or are currently treated for:

















Allergies

Are you allergic to latex?*
Do you suffer from any other allergies?*
* If yes please list:

Immune system

Do you think you may have contracted HIV?*
Do you think you may have had contact with Hepatitis B or C viruses?*

Miscellaneous

Do you smoke?*
Are you currently taking any medication?*
*If yes please list:
Have you ever experienced excessive bleeding from a dental extraction?*
Have you ever had a reaction to any local or general anaesthetic?*
Women: Are you currently pregnant?*
Are you in a Private Health Fund?*
* If yes which one:

Are you a human?

What is 2+3?

Okay ready to go?

Please be sure you have answered all the questions above, and click below to send to us

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