Patient Appointment Request Form

1
Do you have a confirmed diagnosis of COVID-19?* This field is required.
YESNO
2
Have you had close contact with other people in the last 14 days who are probable or confirmed to have COVID-19?* This field is required.
YESNO
3
Are you waiting for a COVID-19 test or the results or are you a probable COVID-19 case?* This field is required.
YESNO
4
Have you been at a current contact tracing location of interest – identified by the Ministry of Health?* This field is required.
YESNO
5
Have you travelled overseas in the last 14 days and been required to quarantine on your arrival to New Zealand?* This field is required.
YESNO
6
Have you exited from an MIQ facility in the last 14 days? If yes: Are you are recovered COVID-19 case? * This field is required.
YESNO
7
Have you had direct contact with someone in the last 14 days who has recently travelled overseas and been required to quarantine on their arrival to New Zealand? * This field is required.The following staff are considered to have either travelled overseas or had direct contact with someone who has, who is required to quarantine: o border staff (international airport and maritime port) o quarantine and isolation facility staff o international air crew and shipping vessel crew, except those who have travelled exclusively in the last 14 days between New Zealand and destinations with which New Zealand has QFT.
YESNO
8
Have you cleaned at an international airport or maritime port in areas/conveniences visited by international arrivals in the last 14 days? If yes: Were these areas used by travellers from countries/areas with which New Zealand has QFT?* This field is required.
YESNO
9
Have you worked in cold storage areas of facilities that receive imported chilled/frozen goods directly from an international airport or maritime port in the last 14 days?* This field is required.
YESNO
10
ALERT LEVEL 3 - 4

Sorry, we are unable to see you for a face to face appointment.

Please click NEXT to complete the rest of the form for a phone consultation.
11
Do you, or anyone living with you have the following symptoms* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Headache
Runny Nose
Sneezing
Sore throat
Loss of smell
Persistent Cough
Shortness of breath
Fever
Nausea/Vomiting/diarrhoea
Headache
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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12
Do you, or the person have following diseases* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
Heart disease
Lung disease
Kidney disease
Diabetes
Auto-immune disorders
Heart disease
YesNo
YesNo
YesNo
YesNo
YesNo
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Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
14
Your Name* This field is required.
First Name
Last Name
15
Address* This field is required.
Street Address
Suburb
City
State / Province
Postal / Zip Code
New Zealand
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
16
Email* This field is required.
example@example.com
17
Phone Number* This field is required.
Area Code
Phone Number
18
Date of Birth* This field is required.
Date
Day
Month
Year
19
Which dental service are you after?Please select all that apply
Hygiene Treatment
Fillings
Extraction
Crowns
Denture
Toothache
Regular dental check up
Full dental examination
Whitening
Orthodontics
Public Funded Dental service
ACC dental related treatments
Other
20
Please describe the nature of your dental problem.* This field is required.Include location of problem ie. top/bottom, left/right, front/back teeth, face/gum swelling, pain scale 1-10, pain relief or medications taken. ability to eat.
Huge
Large
Normal
Small
Ok
Ok
21
Please Take 2-3 photos. Use Flash and Focus the image. One close up shot and one further away. Include a Full Face photo if there is a swelling to help us compare both sides of the face.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
22
Preferred Appointment Date & TimeWe will contact you as soon as possible about your appointment request
23
Preferred Payment Options* This field is required.Please select all that apply
AfterPay
Direct Bank Payment
Cash
EFTPOS / CREDIT CARD
Payment Plan
Other
24
DIRECT BANK PAYMENTS

Pre-payment of $20 is required for prescriptions
25
AfterPay: 3% Surchage applies
26
CASH PAYMENTS

Unfortunately due to health & safety, we currently do not accept cash payments.
27
We will contact you to arrange your appointment based on your preferred date & time.

New to Dental Wellness Centre:
A mandatory NEW Patient Registration Form must be completed before you can be seen by our dentist.
28
I CONFIRM THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. * This field is required.
Should be Empty: