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New Patient Form

Please fill in the form below and we will contact you.

TITLE
- MR
- MRS
- MISS
- MS
- DR
NAME*
First Name Surname
ADDRESS
Street Address Address Line 2
MAILING ADDRESS IF DIFFERENT
Mailing Address Address Line 2
DATE OF BIRTH*
DD slash MM slash YYYY
HOME PHONE*
BUSINESS PHONE
EMAIL*
OCCUPATION
HOW DID YOU COME TO KNOW ABOUT US
Kindly tick ONE of the boxes below
- SIGNAGE
- NEWSPAPER
- RADIO
- WEBSITE
- SOCIAL MEDIA
- RECOMMENDED
Please put in the recommended Name
IS ANOTHER MEMBER OF YOUR FAMILY A PATIENT AT OUR PRACTICE?
- NO
- YES
Please put in the other family member's name
What is your dental concern?*
- Toothache
- I need an Exam
- I would like an implant consultation
- Other
Enter other dental concern details
PLEASE TICK IF YOU HAVE HAD ANY OF THE FOLLOWING:
ANY ALLERGIES
ANY ALLERGIES
- ANESTHETICS
- PENICILIN
- LATEX
- OTHER (please list)
- ALLERGIES TO MEDICINES (please list)
- ARTIFICIAL JOINTS / PINS / PATES: If so, the year of surgery
- ARE YOU CURRENTLY TAKING ANY DRUGS / MEDICATIONS (please list)
- ARE YOU PREGNANT? If so, how many months:
Other (please list)
Allergies to Medicines (please list)
Year of surgery
Please list drugs / medication
How many months pregnant?
MEDICAL CONDITIONS
MEDICAL CONDITIONS
- ANEMIA OR BLOOD DISORDERS
- ARTHRITIS
- ASTHMA
- BLEEDING DISORDERS / EXCESSIVE BLOOD LOSS
- BRONCHITIS / CHEST PROBLEMS
- DEPRESSIVE ILLNESS
- DIABETES
- DRUG DEPENDENCE
- EPILEPSY
- GASTRIC PROBLEMS
- HEART PROBLEMS
- HEPATITIS A, B, C, D, E
- HIGH BLOOD PRESSURE
- HIV VIRUS
- KIDNEY / LIVER TROUBLE
- RHEUMATIC FEVER
- CURRENTLY A SMOKER
- THYROID PROBLEMS
- TUBERCULOSIS (TB)
HOW MANY PER DAY?
I agree that the information gathered can be used for education and debt collection purposes. I agree to be responsible for the payment of all fees and collection costs on overdue accounts through Baycorp. Cancellation of appointments less than 24 hours will incur a fee of $65 per half hour. I have read and agree with these conditions.
PAYMENT IS TO BE AT THE TIME OF YOUR DENTAL VISIT.
SIGNATURE*
DATE:*
DD dash MM dash YYYY

Comprehensive Dental Exams
Emergency Care
Crowns and Bridges
Natural Looking Fillings
Root Canal Therapy
Wisdom Teeth
Gum Disease
Dentures
Extractions

Comprehensive Dental Exams
Emergency Care
Crowns and Bridges
Natural Looking Fillings
Root Canal Therapy
Wisdom Teeth
Gum Disease
Dentures
Extractions

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- Patient Information

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