High Blood Pressure Patients and Asthma Patients, Bronchitis Patients

How would you like to be contacted to notify you are due for a check up and clean?

Please tick appropriate:

Home phMobileWork phMail

Do you have Health Insurance for dental treatment?
YesNo

Referred By:

Are you receiving any medical treatment at the present time?
YesNo

Have you been a patient in hospital during the past two years?
YesNo

Have you taken any medicine tablets, capsules or drugs during the past two years?
YesNo

Have you experienced any allergies or unusual effects from: tablets, drugs, injections or anaesthetic?
YesNo

Are you, or have you been, under the care of a doctor during the past two years?
YesNo

Do you smoke?
YesNo

Have you had any prosthetic surgery? If yes, when? (E.g. Heart Valve, Hip Replacement, Knee Replacement etc)
YesNo

Women Only: Are you pregnant?
YesNo

Do you have Dental pain or a Dental problem at present?
YesNo

Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?
YesNo

Do you become anxious or uncomfortable when you are having dental treatment?
YesNo

I acknowledge that I am responsible for all costs of treatment incurred. Payment for treatment is due on the day of treatment.

New Patients Questionnaire