New Farm Dental Studio - New Patient Form

Personal Details
Title:*
Name*

First NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Private Health Fund
Phone Number
Mobile*
Emergency Contact Name*
Phone Number
Doctors Name (GP)
Phone

Area CodePhone Number
How did you hear about us?*

GoogleWebsiteWord of MouthSignageCinemaSocial MediaOther
Has one of our valued clients referred you? If yes, who can we thank?
Medical History
Are you currently taking any medication? *
Please give details
Have you had any recent or planned surgery?*
Please give details
Have you had any allergies or anaphylaxis?*
Please give details
Ladies, are you pregnant? *
If yes, how many weeks?
Please give details
Are you nursing?*
Do you have any of the following:

Heart problemsThyroid disorderDo you smokeBleeding disorderSinus problemsPaget's or Sturge WeberHepatitis A, B or CRecurrent headachesHead or neck radiotherapyOcular hypertensionRheumatic fever/ Valve replacementHigh/ Low blood pressureDiabetesArthritisKidney/ Liver disorderReflux, crohns, ulcerative colitisEpilepsyAnaemiaAsthmaOther medical issues
About you
What is the reason for your visit today?*
When was your last dental examination / clean?
Do you have any specific dental questions?
Would you like to have whiter teeth?*

YesNo
Are you interested in straightening your teeth with Invisalign?*

YesNo
How do you feel about your visit today?*

RelaxedOkNervous
Consent
I authorise the dentist to take x-rays, study models, photographs and other diagnostics that are appropriate to make a full

assessment of my dental needs.

I authorise the dentist to perform all recommended treatment mutually agreed upon and to employ such assistance as

required to provide appropriate care.

I authorise New Farm Dental Studio to contact me via my given phone numbers/ email as required, to confirm or discuss appointments and to send information relevant to me.

Your personal information will not be passed on to any third party without your consent.
YOUR COMMITMENT TO US:
I acknowledge that I will pay for my treatment in full at each appointment (we accept all health funds, cash, cheques,

EFTPOS, MasterCard/Visa/Amex, Zip Pay and Denticare Payment Plans

I acknowledge that as a courtesy, I will give at least 24 hours' notice if I need to reschedule an appointment.
SIGNED:*

PatientParentGuardian
Clear
Date*

MonthDayYear
Date
Should be Empty:

Personal Details

Medical History

About you

Consent

YOUR COMMITMENT TO US: