Please fill out this form if you are visiting us for the first time. All information is treated as confidential.
Title Mr.Mrs.Miss. First Name Last Name
Date of Birth Occupation/School
Address Suburb Postal Code
Email Telephone Home Mobile Work
Next of kin name and contact details in case of emergency need
Name of Doctor/Medical Practice
Are you taking any prescription or non-prescription medication, pills, or inhalers? YesNo If yes, please list:
Have you ever had any allergies to medications or other substances (e.g.Latex) YesNo If yes, please list :
Have you ever had any of the following: Heart Murmur YesNo Open heart surgery YesNo High or low blood pressure YesNo Rheumatic fever YesNo Other heart trouble/stroke YesNo Asthma YesNo Chest/lung/breathing problems YesNo Eczema YesNo Epilepsy YesNo Radiotherapy or Chemotherapy YesNo HIV/Hepatitis B or C YesNo Diabetes YesNo Tuberculosis YesNo Bruising or blood disorder YesNo Other infectious diseases YesNo Depression/anxiety or stress YesNo Smoker YesNo Any artificial joints YesNo Any Bisphosphonate medications, including Fosamax YesNo Any excessive bleeding from previous surgery or dental treatment YesNo Any reaction to anesthetic YesNo Women: Are you pregnant or breastfeeding? YesNo Any other health matters that you think you should let the dentist know:
I confirm that the information provided above is true and correct to the best of my knowledge.
Name of patient/parent/guardian Date