Patient Form

At Painless Dental we strive to provide you with the highest possible care. To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present. Without this information it is difficult for your dentist or hygienist to plan your care properly.

Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation. If you would like any further information about how we use and protect your personal information, please ask one of our staff for our brochure “Personal Information, Privacy and your Dentist”.

If you don't wish to complete the form online, you can download the PDF version here.

Patient Information
Title:
Surname:* Given Name:*
Preferred Name: Date of Birth:*
Address:* Suburb:*
Postcode:*
Ph (home):* Mobile Number:
Ph (work):
E-mail:*
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:
Reminder System

We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.
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)
:
Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify):
What medications including natural remedies are you taking?:
Have you been hospitalised at any stage? If yes, please detail.:
How did you hear about us?
Referral Source:    
Keep Informed 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.
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.

 

Patient Referral Reward
New Patient Offer
Corporate Dental Program

Opening Hours

Mon - Fri:  7.30 am – 4.30 pm

Visit Us

Public Transport:

Kelmscott train station 5 minutes walk away

Parking:

26 parking bays at the rear

Disabled Access:

Ground floor with wide access to some dental rooms

Find us on google maps

Patient Forms

Click here to complete or download our medical and dental history form before your first appointment.

Any surgical or invasive procedure carries risks. Before proceeding with a surgical or invasive procedure, you should seek a second opinion from an appropriately qualified health practitioner.

Copyright (c) 2011 Painless Dental | Partner of Dental Corporation & DENTAL CARE NETWORKTM | Web Design Sydney by Quantum Web Solutions