E Form

    Please fill out all the necessary information on this form and click on SUBMIT FORM at the bottom of the page; when you sign the bottom of this page you agree that you are happy for your information to be used by any dentist/staff member in accordance with your treatment.

    Title

    First name

    Surname

    D.O.B.

    Mobile

    Phone

    Address:

    Suburb:

    Postcode

    Email :

    Emergency/secondary contact name and number (Please provide Guardian if under 18):

    Referral Source?

    Do you have private insurance with dental cover, if so which fund?

    When was your last dental visit and x-rays?

    Do you have allergies to any drugs, medicines or latex?

    If yes

    Please state ALL medications you are currently taking including bisphosphonates or blood thinners:

    Do you or have you ever suffered from any of the following? If so, please elaborate in the space provided.

    RHEUMATIC FEVER

    HEART PROBLEMS

    ANAEMIA

    TUBERCULOSIS

    HEART VALVE (PROSTHETIC)

    DIABETES

    TUMOUR HISTORY

    CARDIAC PACEMAKER

    ARTHRITIS

    CHEMOTHERAPY

    HEPATITIS A, B OR C

    ASTHMA

    RADIATION THERAPY

    HIV/AIDS

    EPILEPSY

    HIGH BLOOD PRESSURE

    KIDNEY DISEASE

    SINUS PROBLEMS

    LIVER DISEASE

    BLEEDING DISORDERS

    OSTEOPOROSIS

    SMOKER

    FITS OR SEIZURES

    PROSTHETIC JOINTS

    PREGNANT

    OTHER MAJOR SURGERY OR CONDITIONS:

    BY SIGNING THIS FORM, I UNDERSTAND ALL ACCOUNTS ARE TO BE PAID ON THE DAY OF TREATMENT IN FULL

    I confirm that when attending the clinic I will ensure I have no symptoms of Covid-19 and have not been in contact with anyone with Covid-19 and consent to a temperature check onsite.

    Signed

    Date

    We endeavour to provide a service to meet all of your dental requirements, to assist us in this we ask you to please fill out the questionnaire below:

    What is the main reason for your visit today?

    Are you happy with the appearance of your teeth/smile?

    Are you in need of emergency dental work?

    Please list any dental concerns you may have :

    Please click any other of the following services or treatment options you may wish to discuss with your dentist:

    • - Teeth whitening
    • - Orthodontics or straightening of the teeth
    • - Cosmetic treatment to enhance your smile
    • - Replacing missing teeth
    • - Preventative dentistry
    • - Financing options/ Payment Plans

    Please speak to your dentist about any concerns you may have in regards to any available treatments. We are able to provide a written quote to you at the end of your initial consult.