New Patients Form - East Bentleigh Dental Group

Title

Patient Surname

Patient Given Name

Patient Date of Birth

Address

Suburb

Postcode

Telephone: (Home)

Telephone: (Work)

Mobile

Email

Occupation

Heath fund for dental benefits

Yes

No

How did you find out about our practice?

Emergency Contact

Telephone

Medical Practitioner

Telephone

Person Responsible for Payment of Account

Myself

Other

Full Name

Relationship to Patient

Address

Suburb

Postcode

Tel: (Home)

Tel: (Work)

Mobile

Patient Medical History

Are you or have you ever been treated for the following? (Please tick)

Are you happy with the appearance of your teeth?

Yes

No

Do you have any artificial body parts including heart valves joints etc?

Yes

No

Do you have any drug allergies?

Yes

No

Are you currently taking any medication?

Yes

No

Have you ever had an unfavourable reaction to local or general anaesthetics?

Yes

No

Are you pregnant?

Yes

No

I certify that the above information is true and correct. In accordance with the Privacy Act (1988) I authorise any person or company to give information as may be required in response to credit inquiries. I have read and understand the TERMS AND CONDITIONS OF TRADE (overleaf) which form part of, and are intended to be read in conjunction with this Patient Information Form and agree to be bound by these conditions.

If unable to keep appointment 24 hours notice should be given or a fee may apply.

Signature:

Date:

Dental Care

with pain free experience

Patient Information Form

Patient Medical History

Request an Appointment

Dental Care with pain free experience

Patient Information Form

Patient Medical History

Request an Appointment

Dental Care

with pain free experience