client-contact-form


Contact our experienced dentists in Belconnen


Please fill out your personal details and answer the following questions below to register as a new patient at Belconnen Dental Centre. You will be required to sign a hard copy of your registration form when you attend our clinic in person. Thank you

Client contact form

Details

 Yes
 No
Heart problems
Blood pressure high/low
Artificial joints
Rheumatic fever
Circulatory problems
Radiation treatment
Excessive bleeding
Excessive bruising
Ulcers (stomach)
Sinus trouble
Tumour history
Any serious illness
Bone disease/Osteoporosis/Bone cancer
Allergy to anaesthetics
Allergey to Penicillin
Allergy to Medications
Allergy to latex
Anaemia/other blood disorders
Diabetes
Asthma
Hepatitis A B C D E
Epilepsy
Liver/Kidney disease
Mental illness/depression
 Yes
 No
 Yes
 No
Does your jaw click or hurt?
Do you feel you grind your teeth?
Have you ever had specialist treatment?
Do you wear a night guard?
Have you ever had gum disease?
Have you ever had your bite adjusted?
Do you bite your lips or cheek often?
Do you have occasional bad breath?
Do your gums ever bleed when you brush your teeth?
Do you experience sensitivity with hot/cold?
Does floss ever tear between your teeth?
Bone disease/Osteoporosis/Bone cancer
Do your teeth ever hurt when you bite/chew too hard?
 Yes
 No
 Yes
 No

I hereby authorise the dentist or designated team to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anaesthetic sedatives and other medication as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand I can ask for a complete recital of any possible complications. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made. I authorise that this data may be reviewed by team members of the dental practice.

 Yes
 No

Call us today on  02 6251 5635  for more details about our dental care services in Belconnen.

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