Day	Hours
M	Closed
T	09:00 AM – 05:30 PM
W	09:00 AM – 05:30 PM
T	09:00 AM – 05:30 PM
F	10:00 AM – 06:30 PM
S	09:00 AM – 03:00 PM
S	Closed

New Patient & Dental History Form

We are pleased to welcome you to our practice. Please complete the form. The following information is necessary to enable us to provide you with your best dental care. All information disclosed is confidential.

What is the main purpose of your visit today?

General Implants Orthodontics Emergency

(Please specify):

PERSONAL DETAILS

First Name:

Last Name:

Email:

Date of Birth:

Occupation:

Phone:

Address:

Member Number:

Health Fund:

Emergency Contact Name:

Emergency Contact Number:

To complete only if the patient is under 18 years old

Guardian Name:

Guardian Phone Details:

Guardian Contact Address:

REFERRAL INFORMATION

CONSENT FOR SERVICES

• I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics as indicated and I will assume responsibility for the fees associated with those procedures.

• I understand that the practice requires at least 48 hours notice if I need to cancel my scheduled appointment and hat a cancellation fee may apply.

• I am aware that payment is required on the day of treatment.

• We provide as a courtesy to our patients a preventative recall program that offers a recall reminder if you have not been to the practice in 6 months.

Do you wish to receive a recall reminder?

Yes No