Adelaide Endodontic Specialists

New Patient Form

Please fill out the online form below or alternatively download the PDF version here.
Fields marked with an asterix (*) are required fields.

PATIENT DETAILS

Title *

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

Occupation *

Home Phone *

Work Phone *

Mobile *

Email Address *

Street Address *

Suburb *

State *

Postcode *

Postal Street Address

Postal Suburb

Postal State

Postal Postcode

Dental Benefit Fund

Person/Third Party Responsible for Payment of Your Account, Claim/Card Number (e.g Workcover or DVA)

EMERGENCY DETAILS

Emergency Contact *

Relationship to Emergency Contact *

Emergency Contact Number *

Medical Doctor *

Medical Doctor Contact Number *

Other Medical Specialists

REFERRING DENTIST

Referring Dentist

Referring Dentist Location

Do you see any other Dentists or Dental Specialists

IF UNDER THE AGE OF 18, PLEASE FILL OUT THIS SECTION

Father's Name

Father's Contact Number

Mother's Name

Mother's Contact Number

Preferred Contact Regarding your Dental Treatment

Relationship to preferred contact

Preferred Contact Phone Number

MEDICAL QUESTIONNAIRE

MEDICATIONS

Please list all medications, prescribed or otherwise, that you take routinely or at present:

PREVIOUS DENTAL EXPERIENCE

Have you had any problems with dental treatment in the past? *

no
yes

If Yes, please explain:

OTHER RELEVANT HISTORY

Are you pregnant? *

no
yes

If Yes, please indicate how many weeks:

Are you currently undergoing any medical investigations? *

no
yes

If 'Yes', please specify:

Have you been admitted to hospital or needed emergency care in the past 12 months? *

no
yes

If 'Yes', please specify:

Is there any other information that should be known about your health (eg. hearing aids, neck/back disorders etc.)?

Is there any issue that you would like to discuss with the Dentist in private?

no
yes

yes

To the best of my knowledge, all answers to the preceding questions are correct. I understand that it is my duty to inform the dentist should any of my medical circumstances change. I have read the Adelaide Endodontic Specialists Privacy Policy