New Patient Registration

New Patient Registrationbrandtashley2019-03-20T15:52:47+13:00

Complete the form below or download this PDF and bring into our clinic.

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1 Step 1

Personal Details

Titlepick one!

First Name

Last Name

Date of Birthyour full name

Address Line 1

Address Line 2

Address Line 3

Phone Number

Occupation / School

Emergency Contact Nameyour full name

Contact's Relationship to Youyour full name

Emergency Contact Phone Number

Dental / Medical Insurance Provider

Medical Questionnaire

Please tick if yes

Heart Problems / SurgerySmokerBlood PressureAsthma / Lung ProblemsRheumatic FeverDiabetesBlood / Bleeding DisordersJoint ReplacementOsteoporosis / Bone ProblemsStrokeHave you ever taken Fosamax or another bone medication?EpilepsyRadio / ChemotherapyOrgan TransplantHepatitis / Liver DiseasePregnant (how many weeks?)HIV

If any of the boxes above ticked, please provide details heremore details

0 /

Any allergies

Current medications

GP and Practice

Declaration

Although rare, accidental injury to your dentist and staff can occur from the handling of sharp instruments. If this happens during the course of your treatment, our practice requires both the patient and staff member to undertake a blood test.

Do you agree to a confidential blood test if required?

I understand that payment is required at the time of treatment / consultation. Missed appointments, late attendance or cancellation with less than 4 hours notice will incur a fee of $85 per 30 minutes of scheduled time.

As a health service provider, The Dental Centre is obligated to treat you in a manner compliant with the Health & Disability Commissioner’s Code of Rights. These can be made available to you upon request.

Signature (Type name)your full name

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