New Patient Form

At my.dentist.nq we strive to provide you with the highest possible care. To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present.  Without this information it is difficult for your dentist or hygienist to plan your care properly.

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 brochure “Personal Information, Privacy and your Dentist”.

Patient Information
Title:    
Surname:* Given Name:*
Preferred Name: Date of Birth:*
Address:* Suburb:*
Postcode:*    
Ph (home):* Mobile number:
Ph (work):  
E-mail:*
Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
Vet Affairs 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.
How did you hear about us?
Referral Source:    
Dental History

How long is it since your last thorough dental examination?

Please tick any dental concerns you have?
















Medical History

How do you rate your general health?
Who is your general practitioner?
Telephone:
Have you had or are you suffering from any of these?  (please tick)


























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

What medications including natural remedies are you taking?
Consent for Services

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.

 

New Patient Offer $195

The New Patient Offer includes a Full Mouth Assessment performed by the Dentist followed by a Professional Clean and Polish treatment with our Hygienist. Please mention this offer when book your dental visit.

Patient Referral Reward

It gives us great pleasure knowing so many of our patients have referred our high quality service to family, friends and colleagues. We appreciate this and have sent out many rewards to our patients to say thank you for the referrals.

Corporate Dental Program

my.dentist.nq along with DENTAL CARE NETWORK ™ is offering the Corporate Dental Program which provides you with exclusive benefit of a complimentary $100 service voucher to be redeemed for dental treatment if you are an employee of one of our partnered corporate programs.

First Visit?

Complete our medical and dental history form before your visit.

Any surgical or invasive procedure carries risks. Before proceeding with a surgical or invasive procedure, you should seek a second
opinion from an appropriately qualified health practitioner.

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