New Patient Online Form

Surname

Given Names

Title
Mr. Mrs. Dr. Miss Ms. Mx. Ind. Per. Misc.

Date of Birth

Occupation

Phone (Home)

Phone (Work)

Phone (Mobile)

Home Address

Postal Address

Email Address

Emergency Contact - Name

Emergency Contact - Relationship

Emergency Contact - Phone

Emergency Contact - Mobile

Contact preference for appointment confirmation by
SMS Email Home Phone Work Phone Mobile

Referral Information
Dentist Doctor Internet/Website Yellow Pages Local Directories Newspaper Other Patient

Health Fund Details

Veterans Affairs Details (DVA)

Spouse/Partner's Name

Is the patient under 18 years old?
Yes No

Father’s Name (if patient is under 18)

Mother’s Name (if patient is under 18)

Child lives with (if patient is under 18)

Person Responsible for account

Address (if patient is under 18)

Telephone (if patient is under 18)

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Consent for X-rays/photos for educational purposes
Yes No

Dental Health History
Prefer to save your teeth Want complete dental care Are apprehensive about dental treatment Had problems with previous dental treatment Happy with the appearance of your teeth Gums bleed easily Gums feel swollen or tender Teeth feel loose Gums bleed when you floss Suffer difficulty/discomfort when chewing Teeth are sensitive You have missing teeth You think you may have rapidly decaying teeth Have lost or broken fillings Have a dry mouth Have an unsatisfactory denture Discoloured teeth Have a toothache Grind or clench your teeth Worn or broken teeth Suffer pain in the face cheeks jaws joints throat or temples Hear sounds (clicking) from your jaw Pain with hot, cold, sweet, or sour food Take medication for pain

Medical History
Lung condition Heart condition Gastrointestinal condition Nervous or Psychiatric condition Blood disorders Blood-borne viruses Blood Pressure Problem Bone disease Back Problems Neck Problems Fainting Spells Eye conditions High Cholesterol Immune condition Tuberculosis or other respiratory disease Diabetes Liver disease Kidney disease Neurosurgery Smoking Prior hormone treatment Pregnancy CJD or related diseases Stroke Thyroid Skin Conditions Epilepsy or Seizures Dementia Other ongoing conditions

First Name

Last Name

Relationship

Person Responsible for account

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Date

ARE YOU ALLERGIC OR HAVE YOU REACTED ADVERSELY TO ANY OF THE FOLLOWING?
Local Anaesthetics Penicillin or other antibiotics Sulphur Drugs Barbiturates, Sedatives or Sleeping Pills Aspirin Codeine Latex or Rubber Dam Other

Current Prescription Medications

Current Non-Prescription Medications and Recreational/Lifestyle Medications

Ceased Medication including Recreational and Lifestyle Medication

Do you receive any medications in the form of an injection or implant

Are you seeing any other type of Doctor, Specialist, Healer, Naturopath, etc?

Have you been hospitalised or been in any accidents in the last 12 months?

Have you had any operations or surgery?

Do you have any disabilities?

Have you ever taken any other person’s medications?

Have you been diagnosed with osteoporosis or osteopenia?

Have you got cancer or are you having any cancer related treatment?

Medical Doctor’s Name

Medical Doctor’s Address

Last Visit Date

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Date

New Patient Information

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