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New Patient Form

At Sydney CBD 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 fill out the New Patient Form below (or download here) and bring to your first appointment at Sydney CBD Dental. Be reassured that our practice uses patient information in accordance with all State and Federal laws. If you would like to find out more, please see our full privacy policy here

We look forward to meeting you soon.

Please fill out the patient form on a desktop computer.

Patient Details
Title:
Surname:* Occupation:
Given Name:* Private Health Fund:
Preferred Name: Member Number:
Date of Birth:* General Practitioner:
Residential Address:* Contact Number:
Suburb:* Emergency Contact Name:
Postcode:* Emergency Contact Number:
E-mail Address:* Emergency Contact Relation:
Contact (home):*
Contact (mobile):
Contact (work) :
Reminder System:

Please indicate your preferred method of contact:

Medical History: Please tick appropriate box below
Hepatitis
Pregnant: Due date:
Blood Pressure
How many per day:
Diabetes
Joint Replacement:
Other: Are you taking any medications? If yes, please list:

Allergies:

Other (Specify all allergies):
Dental History
Last Visit to the Dentist:
Have you ever had any reaction or complication following dental treatment in the past?:
Is there anything else the Dentist or Hygienist should be aware of?:

Are you suffering from any of the following? Please tick

Discoloured Teeth, Would you like Whiter Teeth?
Privacy and Consent

• Please be assured any information is collected and 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 our staff for “personal Information, Privacy and your Dentist” document.

• I have accurately completed this medical history form to the best of my knowledge. I hereby give my authority for any treatment agreed upon by me, to be carried out by the dentists and their staff and I assume all financial responsibility for all treatment.

• I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependants. I understand that payment is due at the time of service unless other arrangements have been made. We do not offer credit for treatment at Sydney CBD Dental however we do recommend a number of agencies that may offer financial assistance. Please ask our friendly staff members.

• I authorise my dentist to take images of my teeth both before and after my treatment. I understand these images may be used in a practice portfolio to showcase examples of dental work to other patients and my identity will remain anonymous.

• I understand and accept that Sydney CBD Dental requires a minimum of 48 hours notice for cancelling or rebooking appointments. All appointments not attended will be charged at a rate of $75.00. Thank You.

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.
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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.