TitleMr Miss Mrs. Ms Dr Master
Date of Birth:
How did you find us? Google Facebook Word of mouth Board at front Rye Family Clinic Walk by HCF
Other Family Members That Attend Our Practice
How would you like to pay after your appointment?EFTPOS Visa MasterCard Cash
Do you have any private health insurance with dental cover? Yes No
Have you ever had any of the following: (Tick Only For Yes?) Rheumatic Fever Asthma Diabetes Epilepsy Tuberculosis Heart Ailment Kidney Disease Excessive Bleeding High Blood Pressure Hepatitis C Hepatitis B HIV/AIDS
Are you allergic to any drugs, medications or latex? Yes No
Do you have any artificial hip, knee, valve or prosthetic implant? Yes No
Are you currently taking any medications or tablets? Yes No
Ladies: Are you pregnant? Yes No
Ladies: Are you breastfeeding? Yes No
Are You A Smoker? Yes No
Reasons' for this appointment:
How long was your last dental treatment done?
Have you ever experienced any problem with dental injections?
Date
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Call 0480187352