General Information

    Select Title

    First Name

    Last Name

    Date of Birth







    Home Phone

    Work Phone

    Emergency Contact Name

    Relationship to you


    Please complete this section only if you are less than 18 years of age

    Guardian Name

    Guardian Phone Number

    Health Insurance Details

    Do you have Dental Health Insurance?

    Referral Information

    How did you find out about us?

    Medical History

    GP Name

    GP Phone

    GP Practice Address

    Dental History

    Are your teeth ever sensitive to hot or cold?

    Do you grind or clench your teeth?

    Do you use dental floss?

    Would you like your teeth to be whiter?

    Do you play contact sport?

    If so, do you use a mouthguard?

    When was your last visit to a dentist?

    How often do you renew your toothbrush?

    Anything needs to change about your teeth?

    Medical History

    Please describe your medical history?

    Please list ALL your current medications, including over-the-counter and vitamins.

    Allergies/ Adverse Drug Reactions.

    What is the main reason for your visit today?

    Does dental treatment make you nervous?

    Have you ever had or require the following for dental treatment?

    Consent of Services

    New Patient Form