New Patient Registration — Macquarie Fields Dental Care

Personal Details

Name

First Name *

Last Name *

Address *

Suburb

Postcode

Phone

Mobile *

Email

D.O.B *

Health Fund

How did you hear about us?

Will you be interested to provide us with your feedback about our surgery?

Medical & Dental History

Please answer all questions honestly. This information helps us provide safe treatment.

Have you ever had heart trouble or high blood pressure?

Have you been a patient in hospital in the past 2 years?

Are you under current medical treatment?

Are you taking any regular drugs or medicine?

Have you had any other serious illness e.g.: deep ray therapy or cancer?

Have you ever had rheumatic fever, diabetes, hyperthyroidism, asthma, glaucoma, nervous disorder, anaemia, tuberculosis, HIV, hepatitis, epilepsy, psychiatric treatment or strokes?

Have you any known allergies to drugs (especially penicillin), medicines or local anaesthetic?

Women, if pregnant, state how many months?

Who is your regular GP? Name:

Have you ever experienced prolonged bleeding?

Are you a smoker?

Signature & Date

Date *

Signature *

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Macquarie Fields Dental Care

Thank You!