Welcome and thank you for choosing our practice!

If you’re new to Dental Fresh fill out the form below prior to your appointment or you can download a printable version here.

 

01 Personal Information

Next of Kin

Private Health Fund

02 Medical History

Who is your GP?*

Please provide their phone?*

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

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?

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.

Heart/Vascular disorder

Rheumatic Fever

Blood pressure disorder High or Low

Blood disease

If yes, please provide details

Bleed easily

Hepatitis A, B, C

HIV

Diabetes

Liver/kidney disease

Asthma/Epilepsy

Osteoporosis

Have had joint replacement surgery within 2yrs

Other health issues

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

O3 General Informatino

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)

Date*