Add: Ground Level, 150 Collins Street, Hobart TAS 7000 | P: (03) 6224 3207 | E: click here

Your Medical and Dental History

As a new patient we need to get to know you and your medical and dental history so that we can gain a comprehensive understanding of your current and past oral health to provide you with the highest quality treatment. For this reason we will request that you complete a New Patient Form. This can be done in just a few minutes at our practice, prior to your appointment.

However, for your convenience, we have also made this form available online, so the answers will be sent straight to our practice. Alternatively, you can also download to form to complete at a time that suits you.

Download from here.

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:
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)


























Cardiac Conditions
Please tick the following that apply to you.









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.

 

Dentistry

Patient Referral Program


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

New Patient Offer


Comprehensive Dental Assessment (Valued at $268) Includes:

  • Full Comprehensive Examination
  • Professional Clean and Polish
  • Diagnostic X-rays  (if required)
  • Remineralising Treatment

Corporate Dental Program


Denticheck Preventistry 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.