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New Patient Form
Please click
here
to download this form.
Title
Mr.
Mrs
Ms
Other
Surname
First Name
Preferred name
DOB
Best phone number
Email Address
Postal address
How did you hear of us? (Please Select following)
Select
Google
Internet
Social Media
Friend/Family
Patient
Walk-in
Other
Other
Were you referred?
Yes
No
if so, by who,
EMERGENCY CONTACT DETAILS
Relationship to the patient
Emergency contact number
Email
MEDICAL FORM:
Current medical doctors name
Contact number
Practice name
Are you receiving any medical treatment at the moment? If yes, please describe
1. Current medications (prescription/over the counter)
2. Current supplements taken (please list)
3. Smoking status:
Current
Past
Approx how many each day?
4. Do you drink alcohol?
Yes
No
5. Allergy to medications/antibiotics/lates or other
Yes
No
Details
6. Do you have or have had the following?
Heart complaint/treatment
Rheumatic fever or heart valve surgery
High or low blood pressure
Blood disorders
Anti coagulant therapy
Osteoporosis or bone disease
Epilepsy
Hiv or blood borne viruses
Steroid therapy
Stroke
Tuberculosis
Any nervous system disorder
Mental health/depression/anxiety
Gastric ulcer/digestive conditions
asthma/bronchitis/lung conditions
Radiation therapy/chemotherapy
Thyroid disease
Hepatitis - A, B, C ………
Jaundice or other liver disease
Transplanted organ or bone marrow
Arthritis
Kidney disease
Bisphosphonate medications
Joint replacement surgery
Diabetes
Diabetes
Type 1
Type 2
When Diagnosed?
Joint replacement surgery. When Exaclty?
DENTAL HISTORY
When was your last dental examination and hygiene clean?
Are you currently experiencing pain or have a specific dental problem?
Are you wearing a dental appliance
Have you any dental implants?
Do you have bleeding gums or ever been diagnosed or treated for gum diseases?
Is there anything else you would like to talk to your oral health therapist about?
PAYMENT TERMS
Person responsible for the account:
Is the patient
Other
Name
Relationship to patient
Best Contact Number
Email
Address
I understand that Dental in Residence requires payment on the day of treatment with their onsite payment system or account transfer.
I will expect a receipt of services that i can take to my health insurer for rebate.
CONSENT
I AGREE the above is a true and accurate record
I consent to the above forms being embedded into my personal file and kept securely with Dental in Residence
I consent to an initial examination whereby a treatment plan will be outlined to me in written form.
Send
Send
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About Us
Mobile Dental Services
Educational Package
Products
Home
About Us
Mobile Dental Services
Educational Package
Products
Contact Us
0422 274 612
