So we can ensure we are looking after your needs, please review and complete the following questionnaire
Surname*: First Name(s)*:
Preferred Name: Date of Birth*:
Person Responsible for fee (if not yourself):
Do you have Private Health Insurance? ---YESNO If Yes, which company:
How did you find out about our practice? Person Referral, name:
---Walk ByYellow PagesAdvertisementGoogleFacebookOther Social Media
Have you visited our website? ---YESNO Do you “like” us on Facebook? ---YESNO
Have you had any of the follow?
Are you currently taking any medications? ---YESNO
If ‘yes’, please list:
Please list any other allergies:
Have you had any of the following?
Name of your general doctor:
Are you pregnant? YES If yes, what is your due date?
How long since your last dental appointment?
How often do you have dental examinations?
Previous dental x-rays were taken: Less than a year ago Longer than a year ago
Patients Signature*: Date*:
Parent/Responsible Party Signature: Date: