New Patient Form - Adult

Patient Details

Title -- Please Select Dr Miss Ms Mr Mrs First Name * Last Name * Preferred First Name Preferred Last Name Date of Birth * Address * City * Post Code * State * Email * Phone * Work Phone Number Home Phone Number Occupation *

Emergency Contact

First Name * Last Name * Phone *

Person Responsible for fees

Who is responsible for the fees? * -- Please Select Self (skip to next section) Other (enter details) First Name Last Name Address City Postcode State Phone

Health Insurance

Do you have health insurance? * -- Please Select Yes - Dental Yes - Dental and Hospital No Medicare number Individual Reference Number Expiry Date

Medical History

Please select

Rheumatic Fever
Hepatitis
Lung disease
Asthma
Heart problems
Pacemaker
Digestive problems
Diabetes
HIV/Aids
Anxiety
Nasal problems
Sleep apnea
Back problems
Stroke
Infectious diseases
Osteoporosis
Neurological problems
Epilepsy

Major surgery in last 5 years -- Please Select 1 2 3 4 5 Other Other relevant medical history

Are you pregnant or hoping to be so? -- Please Select Yes No If so, how many weeks?

Do you smoke? -- Please Select Yes No How many Cigarettes per day?

Allergies

Do you have any allergies? -- Please Select Yes No Allergies Details

Medicines

Please indicate any medications that you are currently taking or have taken recently (including natural therapies).

Orthodontic information

Have you had previously?

Orthodontic opinion -- Please Select Yes No Orthodontic treatment -- Please Select Yes No Orthodontic treatment details Who is concerned about your teeth and/or jaws? -- Please Select No one Self Your Partner/Family Your Dentist

Work related injury or Transport Accident -- Please Select Yes No Work related injury or Transport Accident Details Do you have a history of trauma to the teeth or jaws -- Please Select Yes No Trauma to the teeth or jaws details

Is ther anything you would like to discuss in private? -- Please Select Yes No

General Dentist

Name of Dentist Location of Dentist Date of last check up

Referrals, correspondence and appointments

Recommended by Email Reports to you -- Please Select Yes No Email reports to dentist -- Please Select Yes No Email reports to specialists -- Please Select Yes No Can we SMS appointment reminders to you? -- Please Select Yes No

I agrree to the Terms and Conditions * Yes