New Patients Questionnaire

Patient Information

Welcome to the Maroubra Dental Centre please fill in the acquaintance form and submit.

    Home phMobileWork phMail

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    Heart TroubleAsthmaHepatitis – Type A, B or CDepressive IllnessEpilepsyKidney TroubleAnaemiaDrug DependenceDiabetesHigh Blood PressureBronchitis/Chest ProblemsArthritisOsteoporosisSevere HeadachesGastric ProblemsCold SoresRheumatic Fever

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