DOR New Customer Registration Form

Health Questionnaire Form

Dental on Raffles. 106 Raffles St, Napier. Contact Phone : 8356253 Dr Gary Winter, Dr Garth Forbes, Dr Tabetha Lindsay, Dr Jaymon Huang, Dr Jess McLeay.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
E-mail*
Preferred Contact Method
Occupation OR School
Name of Last Dentist
How did you hear about this practice?

FriendWord of mouthGoogleFacebookNewspaperOther
If you are under 20 years, please give the name and address of your parent/guardian
Name of the person to contact in an emergency
Emergency Contact Phone Number*
Your Medical Doctor’s name (GP):
Your Medical Doctor's Phone number if known
Would you like to receive emails regarding current promotions?

YesNo
Confidential Health Questionnaire

In order to provide the best and safest dental treatment, your dentist needs to know of any medical problems which may affect your treatment.
Approximately when was the last time you visited a Dentist/Hygienist?
Are you receiving medical treatment currently?

YesNo
Details:
Do you consume alcohol?

YesNo
If yes, how much and how often?
Do you smoke?

YesNo
If yes, are you a: heavy, moderate or light smoker? (Approx amount per day)
Have you ever had any of the following or been treated for?

Rheumatic feverHeart trouble: valve replacement / heart murmurHigh blood pressureAsthmaCold soresDrug dependenceEpilepsyAnginaAnaemiaDiabetesKidney troubleGastric problemsBlood DisordersRadiation TherapyAny blood borne infections (e.g.hep A, B or C, HIV, tuberculosis etc.)Bronchitis or Chest ProblemsSevere headachesDepressive IllnessPeriodontal DiseaseMalignant Hypothermia
Are you a Vegetarian or follow a Vegan lifestyle ?

YesNo
Are you taking any tablets, capsules, medicines or drugs or natural medicines ?

YesNo
If so please list
Have you any allergies to medicines that you are aware of ?

YesNo
If so please list; medicine and type of reaction:
Do you have an artificial or prosthetic joint ?

YesNo
If yes when was this placed?
Have you ever had a reaction to an anaesthetic?

YesNo
Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?

YesNo
If are you pregnant, how many months? i.e 5 or N/A
Do you carry a medical warning card?

YesNo
In case of a medical emergency, I may be required to disclose more information than specified on this form.

YesNo
Are there any other aspects concerning your health that you think your Dentist should know about? Comments or additional information:
I agree that Dental on Raffles has a policy which requires full payment on the day of treatment, unless otherwise arranged with the Dentist or Receptionist, I authorize you to furnish to any third party information held by you for the purposes of administration and protection of such credit. I also understand that any accounts that are deemed overdue will be liable for any and all collection costs including agency fees.
Are you eligible for a quote from Work and Income NZ?

YesNo
Completed by:

SelfParentGuardian
I agree that my submitted data is being collected and stored.*

Yes
Signature

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Health Questionnaire Form

Confidential Health Questionnaire