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Your Name*
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Date of Birth*
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StateNSWVICQLDSAWAACTTASNT
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Your Email*
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Emergency Contact Name
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Person responsible for fees (if not self)
Are you comfortable with therapy/visitation dogs being on site?*YesNoUnsure
How did you find us?*Web SearchSocial MediaWalk PastBy Referral
Do you have any existing medical condition(s)?*YesNo
Are you taking or have you taken any medications?*YesNo
Do you have an infectious disease? (e.g. Hepatitis, Measles, Tuberculosis, HIV, etc)*YesNo
Do you have any allergies or have you had any adverse reaction to any drugs or medications?*YesNo
Do you have any other allergies?*YesNo
Are you a regular smoker?*YesNo
Have you previously smoked before?*YesNo
If you are a woman, are you pregnant?*YesNoUnsure
How often do you drink alcohol?
How often do you have dental examinations?*
When was the last time you had dental x-rays taken?*
Do you suffer from sleep apnoea?*YesNo
Have you received orthodontic treatment in the past?*YesNo
Have you ever had botox or fillers in the lips or face?*YesNo
Do you have current dental insurance?*YesNo
Do you require an interpreter?*YesNo
1. I hereby authorise the dentist or designated team to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis, or to prepare a treatment plan.
2. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other prior arrangements have been made.
3. I authorise that this data may be reviewed by team members of the dental practice and all information collected from you will be used in accordance with our Privacy Policy. To view our Privacy Policy, please request a copy from us.
Please feel free to ask our staff about our fees for dental procedures. We require SAME-DAY settlement of your account. Although we have a HICAPS facility that helps to process your claim, we cannot guarantee that the service will be available at all times.
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