New Patient Form



New Patient Form
Name
Name
First
Last
Do you wish to recieve promotions?
Emergency Contact Name (Please provide Guardian if under 18)
Emergency Contact Name (Please provide Guardian if under 18)
First
Last
Do you have any allergies to any drugs, medicines or latex?

Do you or have you ever suffered from any of the following? If so, please elaborate in the space provided.

RHEUMATIC FEVER
HEART PROBLEMS
ANAEMIA
TUBERCULOSIS
HEART VALVE (PROSTHETIC)
DIABETES
TUMOUR HISTORY
CARDIAC PACEMAKER
ARTHRITIS
CHEMOTHERAPY
HEPATITIS A, B OR C
ASTHMA
RADIATION THERAPY
HIV/AIDS
EPILEPSY
HIGH BLOOD PRESSURE
KIDNEY DISEASE
SINUS PROBLEMS
LIVER DISEASE
BLEEDING DISORDERS
OSTEOPOROSIS
SMOKER
FITS OR SEIZURES
PROSTHETIC JOINTS
PREGNANT
By submitting this form, I understand all accounts are to be paid on the day of treatment in full.

We endeavour to provide a service to meet all of your dental requirements, to assist us in this we ask you to please fill out the questionnaire below:

Are you happy with the appearance of your teeth/smile?
Please check any other of the following services or treatment options you may wish to discuss with your dentist:
Please speak to your dentist about any concerns you may have in regards to any available treatments. We are able to provide a written quote to you at the end of your initial consult.
CANCELLATION POLICY AND ACKNOWLEDGEMENT

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