NEW PATIENT FORM - ADULT


Personal details

Title

First Name *

Last Name *

Preferred Name

Date of Birth *

Home Address *

City *

State *

Postcode *

Email Address *

Work Phone Number

Home Phone Number

Mobile Phone Number *

Occupation *

Emergency Contact

Name *

Phone *

Person Responsible for fees

Person Responsible for fees *
Self    Other

Name *

Address *

Post Code *

Phone *

Do you have health insurance? *

Yes    No

Dental    Hospital

Which Fund?

Medical History

 Rheumatic Fever
 Hepatitis
 Lung disease
 Asthma
 Heart problems
 Pacemaker
 Digestive problems
 Diabetes
 HIV/Aids
 Anxiety
 Nasal problems
 Sleep apnea
 Back problems
 Stroke
 Infectious diseases
 Osteoporosis
 Neurological problems
 Epilepsy

Any major surgery in last 5 years?

Are you pregnant or hoping to be so?
Yes
No

If so, how many weeks?

Do you smoke?

If Yes how many per day?

Any other relevant medical history?

Allergies and adverse reactions

Do you have any allergies?

If Yes state allergy

Emergency plan

Medicines

Please indicate any medications that you are currently taking or have taken recently (including natural therapies).

Orthodontic information

Have you had previously?

Orthodontic opinion:

Orthodontic treatment

In your own words, what concerns you about your teeth, OR What is the purpose of your visit?

Who is concerned about your teeth and/or jaws?

Is this consultation related to Work related injury or Transport Accident?

If Yes, when was the accident/injury?

Do you have a history of trauma to the teeth or jaws?

If Yes, when was the accident and injury?

Is there anything you want to discuss with Dr Yusupov in private?

General Dentist

Name of Dentist

Location

Date of last check up

Referrals, correspondence and appointments

Recommended by

Email Reports to you

Email reports to dentist

Email reports to specialists

Can we SMS appointment reminders to you?

Terms & Conditions *
I agree to be responsible for all payment of fees and understand that payment is due at the time of the service

Enter Verification in box below *


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