(02) 4283 3357

About Us
Services
All On 4
Dental Implants
Digital Smile Design
Patient Info
Blog
Contact Us

Menu

About Us
Services
All On 4
Dental Implants
Digital Smile Design
Patient Info
Blog
Contact Us

ONLINE PATIENT FORM

Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation. If you would like any further information about how we use and protect your personal information, please ask one of our staff for our “Personal Information, Privacy and your Dentist” document. Click here for our privacy policy.

Patient Information

Title

Surname

Given Name

Preferred Name

Date of Birth

Address

Suburb

Postcode

Mobile Number:

Ph (work)

E-mail:

Vet Affairs

Gold White

Vet Affairs Card No:

VA Expiry Date

Name of Private Health Fund (if any):

Position No on Card:

Occupation:

Employer Name:

Next of Kin

Name

Relationship

Phone

In case of an emergency whom should we contact?

Please indicate if different to next of kin.

Name

Relationship

Phone

Reminder System

We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.

SMS Mobile Hm Phone Work Phone E-mail

Dental History

How long is it since your last thorough dental examination?:

Please tick any dental concerns you have?

We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.

Toothache Sensitive Teeth Bleeding Gums Loose Teeth Bad Breath Dry Mouth Missing Teeth Unsatisfactory Denture Rapidly Decaying Teeth Lost Filling/Cavity Grinding/Clenching Teeth Worn, Broken Teeth Pain in Face or Jaw Joints Sounds from Joint Difficulty Chewing Discoloured Teeth Bad Appearance of Teeth Do you, or have you ever smoked?

Medical History

How do you rate your general health?

Excellent Good Poor Fair

Who is your General Practitioner?:

Telephone:

Have you had or are you suffering from any of these? (please tick)

Heart Trouble / Surgery Cardiac Pacemaker High Blood Pressure Low Blood Pressure Diabetes Hepatitis Rheumatic Fever Arthritis Thyroid Trouble Epilepsy Sleep Apnoea Stroke Stomach or Digestive Condition}Reflux Osteoporosis Nervous Disorders Asthma HIVIAIDS Liver or Kidney Disease Are you or could you be pregnant Excessive or Prolonged Bleeding Radiation or Chemotherapy Eating Disorder Prosthetic ImplanVJoint Replacement Organ or done Marrow Transplant Steroid Therapy Other (specify

Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify):

What medications including natural remedies are you taking?:

How did you hear about us?

Referral Source

Consent for Services

Ticking this check box certifies that:

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.

Youtube Twitter Instagram Facebook

Contact Information

(02) 4283 3357
info@ambiencedental.com.au

Suite 3, Level 2, 118-126 Princes Highway Fairy Meadow NSW 2519

Opening Time

Monday - Friday: 8am to 6pm
Saturday. 9am to 1pm
Sunday: Closed

Close Menu