City Dental - Update Your Details

Please complete the fields below if any of your details have changed since your last dental visit. We need certain information so the boxes marked with an asterix must be filled in.

Contact Details

Title(eg. Mr, Mrs) First Name * Surname * Preferred Name * Date of Birth * Home Address

Home Phone Mobile * Email * Name of Workplace Work Address Work Phone Occupation Preferred method of contact Hm Ph. Wk Ph. Mobile Email Txt

Medical History

Doctors Name Doctors Phone

1. Have you been a patient in hospital during the past two years?

No Yes

Reason

2. Have you taken any medicine tablets, capsules or drugs during the past two years?

No Yes

Reason

3. Have you ever experienced any allergies or unusual effects from any tablet, injections or anaesthetics?

No Yes

Reason

4. Are you, or have you been, under the care of a doctor during the past two years?

No Yes

Reason

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5. Are you, or have you been, under the care of a doctor during the past two years?

Epilepsy Rheumatic Fever High Blood Pressure Cold Sores Kidney Trouble Bruising or Bleeding Heart Trouble Low Blood Pressure Severe Headaches

Anaemia Gastric Problems Drug / Alchohol Dependence Arthritis Bronchitis or Chest Problems Asthma HIV Positive (AIDS) Hepatitis - Type A, B, C, D, E

Smoker Heart Murmur Hip or Knee Replacement Dry Mouth Depressive Illness Prosthetic Surgery, Heart Valve Cancer Diabetes

6. If female, are you pregnant?

No Yes

If so, how many weeks? weeks

Dental Information

7. Do you have a dental problem that you would like us to address at your next visit?

No Yes

Describe the problem

8. Do you have any concerns about the appearance of your smile?

No Yes

Describe your concern

Do you have any questions before your next appointment?

Enter any questions you may have

Please note that sudden alterations to our schedule affect other patients from receiving necessary care on time.

Please advise us of a change in your scheduled appointment time at least 3 days in advance.

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Please complete the fields below if any of your details have changed since your last dental visit. We need certain information so the boxes marked with an asterix must be filled in.

Contact Details

Medical History

EXISTING CLIENTS

Dental Information

New Clients

Existing Clients

Services

Our Team

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