If you’re new to Dental Fresh fill out the form below prior to your appointment or you can download a printable version here.
Who is your GP?*
Please provide their phone?*
Do you take drugs/medicine regularly?*
If yes, please provide details
Have you had any serious health issues in the past year?*
Have you ever experienced adverse reaction to any treatment/medication?*
Are you pregnant?*
If so how many months?
Blood pressure disorder High or Low
Hepatitis A, B, C
Have had joint replacement surgery within 2yrs
Other health issues
When was your last dental visit?
How did you hear about us?
Please Note: Settlement of your account is due on the day of treatment. Please see Reception after your appointment to arrange payment. We are happy to reschedule your appointment when necessary, please advise us 24 hours priorly of any reschedule or cancellation requirements. A fee of $75.00 will be incurred for unattended appointments. Sometimes we like to use photos of our work in lectures and on o ther website, if it's ok with you, we'd like your permission to use dental photos for lectures and website usage.
Signature* (Please type your name)
One of our representatives will happily contact you within 24 hours.
Got a question? Call us or use our enquiry form!
Complete an online appointment form here before your first appointment.