Dental Surgery | Canberra, ACT | Belconnen Dental Centre

Belconnen Dental Centre

Suite 204 2nd Floor/54 Benjamin Way, Belconnen ACT 2617, Australia

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New Patient Form

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.

Contact Us

Name

Address

Email

Phone

Date of Birth

Purpose of visit

Is another member of your family a patient at our office

Yes

No

Please tick if you have/had any of the following

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

Additional allergies

Have you been hospitalised in the last 12 months

Yes

No

Are you currently taking any medications

Yes

No

If yes please list

Do you have/had any of the following?

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?

Are you a smoker?

Yes

No

Name of your doctor

Address of doctor

Phone of doctor

Are you pregnant?

Yes

No

How long since your last dental appointment

Health insurance company

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

Patient electronic signature please enter your name

Other notes

Thank you for contacting us.
We will get back to you as soon as possible.

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Contact Information

Address:

Suite 204, 2nd Floor, Belconnen Churches Centre,

54 Benjamin Way, Belconnen ACT 2617

Phone:

Email:

belconnendentalcentre@gmail.com

Fax:

02 6251 5430

New Patient Form

Business Hours

Mon - Fri: 8:00 am - 5:00 pm
Sat - Sun: Closed

By appointment only

Payment Options

Visa Payment Accepted

MasterCard Payment Accepted

American Express Payment Accepted

Cash Payment Accepted

Eftpos Accepted

HICAPS

Enquiry Form

First Name

Last Name

Email

Phone

Message

Thank you for contacting us.
We will get back to you as soon as possible.

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Please try again later.

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