New Patient Form - Parkdale Family Dental

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Please take your time to complete this form in as much detail as possible. All information is kept STRICTLY confidential. We do not share any of your records with anyone unless you authorise us to do so.

Your Details

Name(Required)

Title Given Names Surname

Preferred Name (if any)

Email(Required)

Mobile(Required)

Gender

Date Of Birth(Required)

Day

Month

Year

Occupation

Home Phone

Including Area Code

Work Phone

Including Area Code

Residential Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is your Postal Address the same as Residential Address?(Required)

Yes

Postal Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Do you have private health insurance with dental extras cover?(Required)

Yes

Private Health Fund Name(Required)

Preferred Contact Method(Required)

SMS

Phone

How did you hear about us?(Required)

Google/Website

Walked Past/Business Signs

Family or Friend

Word of Mouth

Facebook or Instagram

Other

Referee Name(Required)

Name of the referee so that we can thank them.

Appointment Booking Experience

On a scale of 1 to 5, where 1 is the least satisfactory and 5 is the most satisfactory, how was your overall experience when booking your appointment?

What could we have done better to improve your appointment booking experience?

Your Emergency Contact Details

Contact Name(Required)

First Last

Contact Phone(Required)

Dental History

Last Dental Exam

When was your last dental examination and clean? If unsure, provide an approximate month and year.

Day

Month

Year

Are you experiencing pain, discomfort or any other problem related to your dental and oral health?(Required)

Yes

If yes, please provide details.

Details

Do you have bleeding gums (e.g. when brushing) or have you been diagnosed with or treated for gum disease?(Required)

Yes

Do you suffer from anxiety from visiting a dentist or have you ever had a bad experience at a dentist?(Required)

Yes

If yes, please provide details.

Details

If yes, please provide details.

Are you happy with the overall appearance of your teeth and smile?(Required)

Yes

If no, please provide details.

Details

Would you like to discuss or find out about any of the following services?(Required)

Teeth Whitening

Invisalign

Crowns & Bridge

Dentures

Dental Implants

Replacement of Amalgam (Silver) Fillings

Other

Purpose of Your Visit(Required)

What is the main purpose of your visit to us?

Your Medical History

GP Name(Required)

GP Contact Details(Required)

Name, address and phone number.

Medical Conditions(Required)

Please select all the medical conditions that are applicable to you. Select "Other" if the condition(s) is not listed. Select "None of the above" if you have no medical conditions to report.

High Blood Pressure

Low Blood Pressure

Diabetes (circle Type I or II)

Asthma/Breathing Problem

Stomach/Bowel Problems (eg Ulcer)

Tuberculosis

Kidney Disease

Thyroid or Endocrine

Excessive Bleeding or Blood Disorder

Epilepsy or Seizures

Hepatitis

AIDS/HIV

Cancer or Tumor

Radiation Treatment

Bone Disorders or Disease

Chemotherapy

Rheumatoid or Arthritic Condition

Acid Reflux

Anaemia or Fainting

Creutzfeldt-Jacob Disease

Special Care or Learning Disability

Mental Condition

Pregnant

Anticipating Pregnancy

Smoker

Other

None of the above

Medical Condition Details(Required)

Please list details for the conditions selected above.

Allergies(Required)

Please list any allergies, including medicines and products (e.g. Penicillin, Latex). If none, please write "None".

Medications(Required)

Please list all medications that you are taking. If none, please write "None".

Consent & Acknowledgement

I have completed this form to the best of my knowledge, and understand that failure to make a full disclosure may place me at undue medical risk. I understand that the payment is due in full the same day as treatment is provided unless agreed in writing prior to starting treatment e.g. approved payment plan. I also give my permission for the practice to use the above contact details to send me an appointment and check-up reminders.

Consent(Required)

I agree to the above.

Signature

Date(Required)

Day

Month

Year

New Patient Forms

Your Details

Your Emergency Contact Details

Dental History

Your Medical History

Consent & Acknowledgement

Parkdale Family Dental: Your Partner in Dental Health

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