This form provides important information required to register as a client in our practice and to deliver your dental care.

Fields marked * must be completed.

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

NEW CLIENTS

Your First Visit Registration Form Consultation Options

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 History

Name of Last General Dentist:

Date of Last Dental Visit: required

7. Do you have Dental pain/problem at present?

No Yes

8. Do you become anxious or uncomfortable when having dental treatment?

No Yes

Dental Appearance

Are you happy with the appearance of your teeth/ smile?

Describe:

How would you like your teeth to look?

Describe:

Referred By:

Friend/Relative TV Magazine Sign

Yellow Pages Internet Yellow Pages Another Dentist or Doctor Website

Brochure/Flyer Newspaper Other

Whom May We Thank:

Examination Preference:(please select one)

Platinum Dream Smile $575 Gold Dream Smile $375 Silver Dream Smile $275 Student Dream Smile (Student ID Only) $180 Cosmetic Consultation $90-15minutes Other - please include details:

Other - please include details:

Dentist Preference: (please select one)

Dr Andrea Shepperson Dr Mark Taylor Dr Ravi De Saram Chantal Jefferies (Hygienist) Other - please include details:

Other - please include details:

Appointment Preferences: (please select one or more)

Mon Tue Wed Thu Fri Any

Preferred Times:

Payment is required at the end of each treatment session, unless by prior arrangement.

Patients are liable for collection fees incurred when accounts are referred to a collection agency.

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This form provides important information required to register as a client in our practice and to deliver your dental care.

Contact Details

Medical History

NEW CLIENTS

Dental History

Dental Appearance

Referred By:

Examination Preference:(please select one)

Dentist Preference: (please select one)

Appointment Preferences: (please select one or more)

New Clients

Existing Clients

Services

Our Team

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