New Patient Form

Please be assured that this information is 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 one of our staff for our “Personal Information, Privacy and your Dentist” document. Click here for our privacy policy.

Your medical and dental history

As a new patient at Katanning Dental Centre, we will ask that you fill in a Medical and Dental Health form before your first visit. For your convenience we have made this form available online so you can print it in advance and email/fax it in or bring it into our practice for your first appointment.

All the information is held in strict confidence and will be used to assist in your dental assessment and treatment planning.

Patient Information
Surname:* Given Name:*
Title: Preferred Name:
Date of Birth:* Address:*
Suburb:*
Postcode:* Preferred Contact Number:
Ph (home):* Mobile Number:
Ph (work): Occupation:
E-mail:* Do you have private health cover?
Next of Kin

(To be completed only if the patient is under 18 years of age)

Guardian Name: Phone:
Address:
Medical History
Name of your General Practitioner:
Contact Number:
Address:
I have medical information that I do not wish to write down and would like to discuss with the dentist in private
Are you allergic to penicillin Are you pregnant or think you may be?
Please list any other known allergies:

Have you a history of any of the following?

Blood Pressure:
If yes, how many per day?:
List current medications:
Dental History
Are you attending for a general check up? Do you have an immediate dental problem?

Are you concerned about or experiencing any of the following dental problems? Please tick all that apply.

Are you concerned with

Do you normally have injections for dental treatment?
How often do you brush your teeth?:
How often do you floss?: Does dental treatment make you nervous
How long since your last dental visit?:*
Is there any other information you feel may be of value regarding your dental treatment?:
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.

 

Please visit this page on desktop to fill up the form.