Patient Questionnaire

Patient Questionnaire

This questionnaire provides the information your dentist needs for your dental treatment and oral health care.
Full name of patient:*

First NameLast Name
Date of birth*

DayMonthYear
Date of birth
Street No. & name:*
Suburb:*
City:*
Postcode:*
Mobile No.*
Work/Landline/Secondary contact No.:
Email:*
Used for confirming this patient's appointment bookings & for any future automatic dental recalls due. Please note parent/caregivers if the patient is under 18 years of age.
Patients Dr/GP:*
Medical Practice/Name of Doctor
Occupation:
Allows us to better understand any possible oral health risk factors as well as consideration to lifestyle.
How did you hear of this practice

Patient recommendationLocal advertising or NewspaperSocial Media/GrapevineGoogleOther
Last dentist/dental practice and approximate date of last visit:*
To ensure the best and safest dental care, it is important for your dentist to be informed of any medical conditions that may impact your treatment.*

Heart AttackHeart MurmurHigh blood pressureHeart Surgery-inc. PacemakerStrokeRheumatic feverAnxiety/DepressionAcid Reflux/GERDArtificial/Prosthetic jointAsthmaChest and lung diseaseSinus/hay feverEpilepsyDiabetesKidney problemsCancer/Radiotherapy/Chemo.Eating Disorder(s)Gastric problemsHad close contact with HIV, Hep B, C, D*Other (please see below)None of the options listed above apply to me
*If you checked other above - please provide details:
Please list all medications:*
Inc. herbal natural supplements, steroids, vitamins currently being or recently been taken by the patient. If none - please confirm this by entering “Nil”
Please list allergies:*
Inc. medicines, penicillin, latex, mint, local anaesthetic etc. If none - please confirm this by entering “Nil”
Are you or could you be pregnant? question*

NoYes/Possible
If you are pregnant, how many weeks?
Although rare, accidental injury to staff can occur during handling of used instruments. If this happens during the course of your treatment, our practice requires both patient and staff member to undertake a blood test. Do you agree to a confidential blood test?*

YesNo
Have you ever experienced excessive bleeding or bruising from dental treatment or at any other time?*

NoYes
Have you ever had an un-favourable reaction to LOCAL anaesthetic?*

YesNo
Please specify average number of alcoholic units you consume per week:*

0 - I don’t drink alcohol1 - 56 - 1415 - 21More than 21
Do you currently smoke or vape - or only recently given up?*

No - I neither smoke or vapeYes - I both smoke & vapeYes - I smokeYes - I vapeI have recently given up smoking/vaping
To ensure sufficient time is allocated, please confirm the nature of your/the patient's appointment:*

Appointments for BOTH dentist & hygienist (allow 60-90 mins)Toothache/Pain (allow 45-60 mins)Regular check-up/consultation with Dentist only (allow 20-30 mins)Scale & polish with hygienist only (allow 45-60 mins)ACC - Arrive 5 mins earlier to complete form (If injury claimed elsewhere previously, we require claim no. Ph ACC: 0800101996)Free Adolescents DB Oral Health Service (allow 30 mins)Available for adolescents in School Year 9 through to their 18th birthday.Second opinion - Bringing recent x-rays/records can reduce costs, time & repeat imaging (allow 30/45 mins)Other
Thank you for choosing the Free Adolescent DB Oral Health Service. To verify your eligibility, an Enrolment Form must be completed, providing the information required by Te Whatu Ora. Please click the link provided upon submission of this form to complete the necessary details.
Is there anything else you'd like to enhance/improve or discuss about your mouth, smile, or oral health with us?
Terms and Conditions

Payment Terms: Full payment is required on the day of the appointment. Unpaid debts may be transferred to a collection agency, including any associated collection fees, which will be the patient’s responsibility.

Accuracy of Information: All provided information must be accurate to the best of the patient's knowledge.

Cancellation & Rescheduling: Cancellations or changes with less than 16 hours' notice will incur a 50% charge of the appointment’s total value.
Cancellations or changes with less than 4 hours' notice, or missed appointments, will incur an 80% charge.

How to Notify:

Email: Reply to the appointment confirmation email or email info@whitforddental.co.nz
SMS/Text: Reply with "N" or "No" to the SMS reminder two days prior.
Phone: Call 09 530 8461, leaving your full name, appointment time, and cancellation/reschedule request if we are unable to answer at the time of your call.
We appreciate your understanding and cooperation in helping us provide efficient and timely care for all our patients.

Please sign below to confirm that you have read, understood, and agree to all the terms and conditions outlined above.
Full name of patient (if 16+ years)/Parent/Legal Guardian:*

First NameLast Name
Signature: *
Date:
Date *

DayMonthYear
Date
Should be Empty: