New Patient Registration — Macquarie Fields Dental Care

Personal Details

Title

First Name *

Last Name *

Address *

Suburb

Postcode

Phone

Mobile *

Date of Birth *

Health Fund

How did you hear about us?

Will you be interested to provide feedback about our surgery?

Medical & Dental History

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?

Have you ever experienced prolonged bleeding?

Are you a smoker?

Who is your regular GP? Name:

Declaration

Date *

Signature *

Sign with your finger or mouse

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Form Submitted!

Your New Patient Registration has been successfully recorded by Macquarie Fields Dental Care.

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