Patient Form

If you have not visited our practice before, please fill out the required fields (marked *) and any other helpful information in new patient form below. This information, which will remain strictly private and confidential, will provide us with a better understanding of your dental and oral health needs as well as your medical history so that we can better serve you at our Sydney dentist office.

If you have any questions regarding this form or to make an appointment by phone, please call 02 9241 2038.

Title*

Name*

First NameSurname

Date of Birth*

DDMMYYYY

Address*

Street Address

Address Line 2

SuburbState

PostcodeCountry

Ocupation*

E-mail*

Confirmation Email

Contact Numbers

Home

Work

Mobile*

Do you have private health insurance?*

Health fund provider*

Member Number*

Patient Number

Person to contact in case of emergency*

Phone*

Referred by*

Please Specify*

General Health Questions: Please mark every box (YES or NO) and specify for each condition*

	YES	NO
Heart Condition
Blood Pressure
Diabetes
Rheumatic Fever
Artificial Valves/prostheses
Heart Murmur
Prolonged bleeding
Gastric Problems
Arthritis
Osteoporosis
Eating disorder
Sleep Apnoea
Asthma
Hepatitis
HIV/AIDS positive
Are you a smoker?
Are you Pregnant?

Do you have allergies?*

Type of allergies*

Do you take any medications?*

Present Medication(s) Taken*

Name of GP

Contact Number

Reason for presenting to the practice?*

ConsultationPainRegular check upOther

When was the last time you visited a dentist?*

Your Smile*

	YES	NO
Are you happy with the look/shape/colour and alignment /spacing of your teeth?
Would you like to know more about Botox offered at Quay Dental for clenching or cosmetic reasons
Would you like to know more about veneers/ whitening or have our gap free Invisalign consultation?

Any other concerns about your smile?

How will you be paying?

Appointment Cancellation

It is our practice policy that you provide at least 24 hours notice if you are unable to keep an appointment. If due notice is not given a fee of $50 will apply for all appointments not attended.

Verification*

PRIVACY: The information provided to us remains private and strictly confidential in accordance with Quay Dental Pty Ltd privacy policy.