New Patient Form

We’d like to get to know you better …

Thankyou for coming to our clinic. To ensure your comfort and most suitable dental care, we ask
you to kindly complete the following questionnaire. Should you have any difficulties the staff are
only too happy to help. All information will be treated as highly confidential.
SURNAME
FIRST NAMES
PREFERRED NAME
HOME ADDRESS

Street Address

Suburb

Postcode
POSTAL ADDRESS (IF DIFFERENT FROM ABOVE)
- YES
Address

City

Postcode
TELEPHONE
MOBILE NO.
EMAIL
OCCUPATION
WORK ADDRESS
TELEPHONE
I WAS RECOMMENDED BY
MY DATE OF BIRTH IS

Day

Month

Year
PERSON RESPONSIBLE FOR ACCOUNT (IF DIFFERENT from above)
NAME
ADDRESS
MY DENTAL INSURANCE FUND IS
MY FAMILY DOCTOR IS
HIS/HER ADDRESS IS
TELEPHONE

We’d like to get to know you better …