NEW PATIENT FORM - ADULT

Personal details

Title
DR MISS MR MRS MS

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?
-- Please select -- Yes No

If Yes how many per day?

Any other relevant medical history?

Allergies and adverse reactions

Do you have any allergies?
-- Please select -- Yes No

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:
-- Please select -- Yes No

Orthodontic treatment
-- Please select -- Yes No

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?
-- Please select -- Self Your partner/family Your dentist No one

Is this consultation related to Work related injury or Transport Accident?
-- Please select -- Yes No

If Yes, when was the accident/injury?

Do you have a history of trauma to the teeth or jaws?
-- Please select -- Yes No

If Yes, when was the accident and injury?

Is there anything you want to discuss with Dr Yusupov in private?
-- Please select -- Yes No

General Dentist

Name of Dentist

Location

Date of last check up

Referrals, correspondence and appointments

Recommended by

Email Reports to you
-- Please select -- Yes No

Email reports to dentist
-- Please select -- Yes No

Email reports to specialists
-- Please select -- Yes No

Can we SMS appointment reminders to you?
-- Please select -- Yes No

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