Patient Registration Form - ADULT
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Give us a big smile and snap a shot!
Contact Number
*
-
Area Code
Phone Number
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State
Postal Code
Next of Kin
NAME
Contact Number
Do you have Private Health Fund
*
Yes
No
Health Fund
Membership and Serie
Medicare
Number
Serie
Medical History
Do you have any allergies (medication, food, latex)?
*
Yes
No
If yes, tell us more ...
If you are an existing Casuarina Dental patient and have previously completed this form, please indicate if there have been any medical changes in the past two years, such as new medications, operations, or allergies.
No
Yes
This is my first-time visiting Casuarina Dental.
GP Doctor
Contact N.
Ladies, are you pregnant?
*
Yes
No
If yes, tell us more ...
Do you drink?
*
Yes
No
If yes, tell us more ...
Do you smoke?
*
Yes
No
If yes, tell us more ...
Do you use recreational drugs?
*
Yes
No
If yes, tell us more ...
Your current medication (including herbal, dietary supplements, naturopathic medicine)
*
Yes
No
If yes, tell us more ...
Do you use medical cannabis?
*
Yes
No
If yes, tell us more ...
Do you have any present illness? if yes, select from the options below.
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Stomach or Digestive Problems
Bleeding Disorder
ADHD
Heart murmur/Heart Disease
Hepatitis
Stroke Blood Pressure High/Low
Stroke Blood Pressure
Thyroid Disorder
Diabetes T1 or T2
Psychiatric Condition
Artificial Heart/ Valves
Valve Defect
Epilepsy
Rheumatic Fever
Taking Bisphosphonates
Bone Disease
HIV
Congenital Heart Defect
None
Other
Please, select from the options below.
*
Kidney Trouble
Infectious Diseases
Cardiac Surgery Pacemaker
Joint Replacement
None
Dental History
If you are an existing Casuarina Dental patient and have previously completed this form, please indicate if there have been any dental changes in the past two years. This includes dental implants, wisdom teeth removal or eruption, pain, or sensitivity.
No
Yes
This is my first-time visiting Casuarina Dental.
When did you have your last dental visit?
-
Day
-
Month
Year
Date
Are you experiencing any pain, or are you concerned about your oral health?
How often do you brush your teeth?
1x day
2x day
3x day
How often do you floss your teeth?
1x day
2x day
3x day
I don't floss
Sleep Apnea. Have you been diagnosed with Sleep Apnea?
*
Yes
No
I don't know
If yes, do you use any CPAP, Sleep Apnea device?
Yes
No
Do you have amalgam/silver fillings?
*
Yes
No
I don't know
If yes, have you heard about SMART protocol?
Yes
No
Do you have teeth alignment issues?
*
Yes
No
I don't know
If yes, have you use/used braces or aligners?
Yes
No
Do you have jaw pain or TMJ issues?
*
Yes
No
I don't know
If so, have you tried Botox for TMJ treatment?
Yes
No
Are you concerned about the color or shape of your teeth?
*
Yes
No
If so, have you done teeth whitening before?
Yes
No
Have you done PRP (Platelet-rich plasma) treatment before?
*
Yes
No
If so, what you have used PRP for?
Gum resection
As a natural alternative to Botox for Skin Rejuvenation
Others
Do you have cold sore/oral herpes frequently?
*
Yes
No
If so, have you ever had ultrasound treatment for pain relief before?
Yes
No
Please, select from the options below.
*
Excessive snoring
Bleeding Gum
Bed wetting
Choking or gasping during sleep
Gum disease
Stop breathing
Lack of energy
Falling asleep or Day tiredness
Poor Concentration
Frequent visits to the bathroom during the night
None
Other
The purpose of dental materials or restorative materials is to replace the tooth structure that has been lost. Restorative materials vary according to their intended use, and their characteristics vary as well:
*
I am happy to let the dentist decide which material is best for each restorative situation, based on knowledge of the material properties, biocompatibility, aesthetics, and application.
I wish to further discuss with my dentist the material to be used.
Would you like to discuss anything with the dentist regarding your oral health or smile appearance?
For your Comfort: There are still many people who are nervous about going to the dentist. Even though techniques and anesthetics have improved, you may still be apprehensive and would like us to take extra measures to ensure your comfort. Please tell us the number that indicates your present level of apprehension:
Easy
1
2
3
4
5
6
7
8
9
Petrified
10
1 is Easy, 10 is Petrified
Privacy Policy
Would you like to receive email communications from us, such as appointment and recall reminders, as well as our newsletter?
*
Yes
No
Do you consent to the use of photos/videos for medical studies, social media, or advertising?
*
Yes
No
Where did you hear about us?
*
Facebook
Instagram
Flyer at your mailbox
I searched on Google
Google advertising
YouTube
Passing by the front door
The Commons advertising
Magazine
TV
Radio
Word-of-Mouth
If you choose Word-of-Mouth. Kindly let us know who referred you to us so that we can thank them.
No accounts are kept in this office; hence is practice policy that payments are to be made on the day of the treatment.
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