Hobsons Bay Dental New Patient Form

CONTACT DETAILS

Title

Gender

Date of Birth

First

Last

Preferred Name (If Different to Given)

Home Address

Address Line 1

City

State

Zip

Country

Mobile Phone / Best Contact No.

Home Phone

Work Phone

Emergency Contact Name

Contact No.

Relationship to You

GP / Medical Clinic Name

Contact No.

How Did You Find Out About Our Clinic?

Name of Referrer / or if Other please elaborate

DENTAL HISTORY

How Long Ago Was Your Last Dental Visit?

Is There Anything Else You Would Like To Discuss With Your Dentist?

MEDICAL HISTORY

Are you curently receiving medical treatment?

If Yes, please provide details

Any Other Serious Illnesses or Operations?

If Yes, please provide details

Are you currently taking any medications?

If Yes, please list them here

Are you allergic to any medications?

If Yes, please list them here

Do You regularly Smoke or Vape?

Females, are you currently pregnant?

ACCOUNT DETAILS

Person Repsonsible For Fees

If Other Please Specify

Are You Covered By Dental Insurance?

Health Insurance Fund Name?

Health Insurance Fund Card Number

Your Line Number

Medicare Card Number

Medicare Card Line Number

Medicare Expiry (MM/YY)

Declaration

I have read and agree to the above statements.

Date

I have read and agree to the Terms and Conditions and Privacy Policy

New Patients

CONTACT DETAILS

DENTAL HISTORY

MEDICAL HISTORY

ACCOUNT DETAILS