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New Patient Form
The information provided in this document ensures we are able to give you the best possible care at Adelaide Dental.
The Information is confidential and we respect the privacy of our patients, and as such will only ask for information relevant to the treatment we may provide you. Thank you!
Patient Information
Title
Surname
(Required)
First Name
(Required)
Preferred Name
Date of Birth
(Required)
Day
Month
Year
Current Address
(Required)
Street Address
Suburb
State
Postcode
Postal Address:
Tick Here If As Above
Postal Address
Suburb
State
Postcode
Phone Number
(Required)
Email Address
Preferred Communication
(Required)
Phone Call
SMS
Email
Mail
Do you have Private Health Insurance:
(Required)
Yes
No
Company
Patient Number Line
How did you hear about us?
How did you hear about us?
Personal Referral
Google/Google Ads
Facebook/Instagram
Health Engine
Other
If Personal Referral, Who Referred You:
Emergency Information
Name
(Required)
Phone Number
(Required)
Relationship
(Required)
Other Information
Job Title
Employer
Hobbies
Dental Information
Purpose of my visit is
(Required)
I have problems with
Sensitivity to Hot and Cold
Staining
Yellow/Dark Teeth
Crowding of Teeth
Bleeding Gums
Food Trapping Between Teeth
Discoloured Fillings
Bad Breath
Grinding and Clenching my Teeth
Clicking/Pain in the Jaw Joints
Rough Fillings/Teeth
Tenderness when Eating
Poor Fitting Dentures
Teeth Breaking Down
How long has it been since your last dental visit?
The following is MOST important to me:
(Required)
General Health and Well being
Look of my Smile
Chewing and Eating
Keep my Teeth for Life
Avoiding Pain
Avoiding Costs
Important Event Coming Up
Anti-aging
Please choose 3 or less only.
Please rate your smile from 1-10, with 10 being best:
(Required)
1
2
3
4
5
6
7
8
9
10
Have you have had a bad dental experience in the past?
(Required)
Yes
No
Does dental treatment make you nervous?
(Required)
No
Slightly
Moderately
Extremely
Please list anything that may make you nervous about a dental visit:
Have dental anaesthetic injections worked well on you in the past?
(Required)
Yes
No
Weight in kilograms
(Required)
Medical Information
It is important that we know your past and present medical information. Many medical conditions and medications may interfere with dental procedures.
Name of your Doctor (GP)
Phone Number
Please list any medication you have taken over the last 12 months:
Add
Remove
Allergies/Reactions? If yes, please list below:
Add
Remove
Have you experienced any of the following before:
Rheumatic Fever
Epilepsy
Diabetes
Asthma
Radiation Therapy
Dizziness or Fainting
Hepatitis A, B or C
Cancer
Heart Murmur
Pacemaker
Smoker
Kidney Disease
Heart Attack
High Blood Pressure
Bleeding Problems
Artificial Joints
Respiratory Problems
HIV Positive
Osteoporosis
High Cholesterol
Heart Rate Problems
Cold Sores
Do you have any medical problem or disease not listed above?
Have you had surgery or been in hospital in the last 5 years?
Are you pregnant?
(Required)
Yes
No
Referral Information
Please list the name and number of anyone you think would benefit from an appointment with our practice:
Name
Phone Number
Name
Phone Number
Name
Phone Number
Payment Plans
Consent
Please tick this box if you would like to discuss a Payment Plan as an option for you.
Claiming
Are you claiming your dental treatment under a Government Dental Benefit Scheme?
(Required)
Yes
No
Are you claiming under Overseas Insurance?
(Required)
Yes
No
Consent Information
Consent
(Required)
This is to certify that the information I have provided is to the best of my knowledge true and I understand that it is my responsibility to inform the practice of any changes in my medical status. I, the undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics as indicated. I will assume responsibility for the fees associated with these procedures. Therefore, I shall pay any legal costs, including solicitor and own costs, tracing costs and any collection costs incurred by Adelaide Dental as a result of my failure to pay any amount due to Adelaide Dental. I authorise the use and disclosure of my graphic/video images by Adelaide Dental to be used for Teaching, Marketing and Education Purposes. I may revoke this at any time, and the revocation must be received by the practice in writing.
(Required)
Consent
I hereby give consent to transfer my dental records or copies thereof (including all photographs, bitewing, PA and OPG radiographs) to: Dr George Mandranis at Adelaide Dental
Previous Dentist Practice Name
Previous dentist address
Street Address
Suburb
State
Previous dentist email address
Signature of Patient/Parent/Person Responsible
Date
(Required)
DD slash MM slash YYYY
