Cosmetic Dentistry, Teeth Whitening & Smile Makeover, Dental Hygiene & Implants

So we can ensure we are looking after your needs, please review and complete the following questionnaire:

In accordance with the Privacy Act your details will be handled with utmost confidentiality and will not pass beyond this practice without your written consent.


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Salutation:

Surname:

First Name:

Date of birth:

/ /

Recommended by:

Address:

Postcode:

Private Phone:

Mobile Phone:

Business Phone:

Email:

Occupation:

Person responsible for fees (if not self):

Purpose of visit:

Dental Insurance:

Yes: No:

Is another member of your family a patient at our office:

Yes: No:

The name of your physician:

Are you pregnant?

Yes: No:

How long since you last dental appointment?:

How often do you have dental examinations?:

Previous dental x-rays were taken:

Less than 1 year: More than 1 year:

I accept the terms and conditions:

Yes No


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MEDICAL HEALTH HISTORY