If the account holder is different to the above please fill out the details below.
Emergency Contact if different to account holder:
Do you or have you ever had a habit of chewing your:
Have you had or are you suffering from any of these? (please tick)
At North Queensland Family Dental we have partnered with Dental Care Network to offer Dentisure™, as a ‘Patient Loyalty Bonus’ to all eligible patients. This includes FREE coverage against dental accidents. If you would like to sign up for Dentisure™ for free and with no ongoing costs ever, simply ask our receptionist at your appointment for more information.
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.
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Mon-Thur: 9am – 5pmFri: 8am – 4pm
Suite 2, 132-134 Ross River RdMundingburra QLD 4812
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Parking is available on site
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