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