Online Patient Form

Patient Details
Surname:* Given Name:*
Date of Birth:* Gender:
Address:* Postcode:*
Home Phone:* Work Phone:
Mobile Phone: E-mail:*
Occupation:
Do you have Private Health insurance?
Name of Private Health Fund (if any):
Family Doctor: Phone:
Person Responsible For Account

If the account holder is different to the above please fill out the details below.

Full Name: Phone:
Address: Postcode:
Relationship to patient Other, please specify:

Emergency Contact if different to account holder:

Full Name: Phone:
Dental History
Are you in discomfort now?
If yes, what is the discomfort?:
Time since last visit:
Are your teeth sensitive to any of the following?
Do your gums bleed? When do they bleed:
Have you ever been treated for gum disease/periodontitis? When?:
How often do you brush?: When?:
Do you use an electric toothbrush? Do you floss?
Do you smoke? If so, how often?:
Have you ever had orthodontic treatment? By Whom?:
Details (please explain duration and type of treatment undertaken): When did you have orthodontic treatment?:

Do you:

Do you have frequent headaches/migraines? Details:
Do you get pain or discomfort in your jaw joint? Details:
Do you snore? Are you a mouth breather?

Do you or have you ever had a habit of chewing your:

Does floss ever tear between your teeth? Does food get caught between your teeth?
Do your teeth ever hurt when you bite hard?
Medical History

Have you had or are you suffering from any of these? (please tick)

If you are taking any medication or drugs, please provide details::
Do you require Antibiotic Cover prior to dental treatment
Are you pregnant?
Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify):
Are there any other conditions this practice should be aware of?:
Patient Loyalty Bonus

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.

Family Members
Names of other family members attending this practice:
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.

 

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