01 Personal Information

Next of Kin

Private Health Fund

02 Medical History

Please select the appropriate alternative, if you answer yes, please provide details in the relevant section below:

Have you ever, past or present, experienced any of the following?

Please select the appropriate alternatice, if you answer yes, please provide details in
the relevant section below.

Please provide a list of any medications you are currently taking.

O3 General Informatino

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.