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    NEW PATIENT REGISTRATION FORM

    PERSONAL DETAILS Please answer all questions. All information is strictly confidential

    Title:MrMrsMsDrMasterMissNo TitleOther

    First Name:

    Surname:

    D.O.B:

    Address:

    Postcode:

    Suburb:

    Home Ph:

    Mobile:

    Work:

    Email:

    Occupation:

    Emergency Contact:

    Emergency number:

    Relationship:

    Do you have Health Insurance?

    Name of Health Fund:

    Membership Number:

    Series number:

    MEDICAL DETAILS

    Medical Practice:

    GP name:

    Address:

    Phone no:

    The state of your health may have significant effect on your dental care and is essential or appropriate treatment planning. Do you have or had you had any of the following: (please tick)

    Medications (please list):

    Do you have any allergies? (please list):

    Do you smoke?

    If yes how many and how long?

    Are you pregnant?

    If yes, how many weeks:

    Are you breast feeding? Y / N

    If yes

    Do you require any extra assistance?

    DENTAL INFORMATION

    1)How would you describe your dental health?

    2)How often do you brush / Floss?

    3)Do you have any dental concerns?

    4)When was your last dental visit?

    Reason:

    Did you have dental X rays taken?

    5) Would you say you have a dental anxiety?

    6) Have you ever had orthodontic(braces) treatment?

    7) Are your teeth sensitive to hot or cold?

    8)Do you grind or clench your teeth?

    9) Do you get clicking or pain in your jaw?

    10) Do you get food trapped between your teeth?

    11) Do your gums bleed?

    12) Do you get bad taste or bad breath?

    13) Do you get mouth ulcers?

    Cosmetic Evaluation

    1)Do you feel confident about your smile?

    2) Do you want to change anything about your smile?

    3) Would you like your teeth whiter?

    4) Would you like your teeth aligned?

    What is the reason for today’s visit?

    How did you hear about us? Internet / Health Fund / Word of mouth / Local / Social Media / Other:

    Payment is required at the time of service.

    To avoid the possibility of incurring cancellation fee, a minimum of 24 hours’ notice is required when cancelling or rescheduling an appointment.

    Keys to smile is committed to complying with all applicable privacy laws.

    I have completed the above questionnaire to the best of my knowledge and understand that failure to make a full disclosure may place me at undue medical risk.

    Sign

    Print name:

    Date:

    Parent / Guardian signature (if required)

    Have any questions?

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