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20 Wetherill St. Leichhardt, Sydney, NSW 2040
CALL US (02) 9569 4274
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Fill the form below
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Step One
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Step Two
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Step three
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Step Four
Personal Details
Title
Dr
Master
Miss
Mr
Mrs
Ms
Prof
Gender
Male
Female
Other
Surname
First Name
Preferred
Date of Birth
Address Line 1
Address Line 2
Suburb
Postcode
State
Email
Phone
Mobile
Occupation
Company Name
Work Phone
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How did you find out about us?
Nova
Radio - Smooth FM
Google
Signage / Walk in
Website
Health Fund
Facebook
Family /friends
Department Of Communities & Justice
Other
Health Insurance
Do you have a Private Health Fund?
Yes
No
Name of the fund
Membership No.
ID# on card (1, 2, 3 etc)
Medicare No.
ID# on card (1, 2, 3 etc):
Emergency Contact
Person to contact in the case of emergency
Relationship to patient
Contact Phone
Contact Mobile
Dental History
When was the last time you visited the dentist?
6mths
1yr
18mths
2yrs
more than 5yrs
How often (daily) do you brush your teeth?
once
twice
3 times
do not brush
How often (daily) do you floss your teeth?
once
twice
3 times
do not floss
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What dental problems do you experience?
Bleeding gums
Bad breath
Tooth discolouration
Painful/sore gums
Sensitivity to hot/cold
Swollen gums
Grinding your teeth
Sharp teeth
Clenching your jaw
Other
Medical History
Do you suffer or have you ever had any of the following medical conditions or treatments:
Anaemia
yes
no
Artificial Joints
yes
no
Asthma / Hay Fever
yes
no
Diabetes
yes
no
Fainting Attacks
yes
no
Hepatitis B
yes
no
H/L Blood Pressure
yes
no
Liver Disease
yes
no
Osteoporosis
yes
no
Radiation Therapy
yes
no
Steroid Therapy
yes
no
Stroke
yes
no
Tuberculosis
yes
no
Arthritis
yes
no
Artificial Heart Valve
yes
no
Blood Transfusion
yes
no
Epilepsy
yes
no
Heart Disease
yes
no
Hepatitis C
yes
no
Kidney Disease
yes
no
Lung Disease
yes
no
Panic Attacks
yes
no
Rheumatic Fever
yes
no
Stomach Conditions
yes
no
Thyroid Disease
yes
no
HIV / AIDS
yes
no
Are you allergic to any of the following:
Aspirin
yes
no
EES Medicine
yes
no
Iodine
yes
no
Panadol
yes
no
Sulpha Drugs
yes
no
Ibuprofen
yes
no
Codeine
yes
no
Epilim
yes
no
Latex
yes
no
Penicillin
yes
no
Pethedine
yes
no
Other allergies
If female, are you pregnant?
yes
no
Approx. due date
What medication/s are you currently taking?
What medical treatment you are currently under?
Do you smoke?
yes
no
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COVID-19
How many shots of the COVID-19 vaccine have you received in the past 24months?
0
1
2
3
4
>4
Have you tested positive to COVID-19 in the past 14 days?
yes
no
Date of when you tested positive
I have answered all the questions to the best of my knowledge and understand that it is my responsibility to inform the surgery about any changes to my medical health and personal details. If further information is required, I give my permission for the surgery to contact my general practitioner. I have read and accept the privacy policy. I understand and accept that a cancellation fee will apply if I do not provide a minimum of 24hours notice of not being able to attend my appointment. I agree to assume complete financial responsibility for my account and understand that full payment is required on or before the day of treatment. I understand and agree that in the event of my account remaining unpaid and being referred to a debt collection agency and/or law firm, all collection and legal demand costs will be added to my account for which I am responsible for.
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Home
Our Dentists
Dental Services
General Dentistry
Sedation
Dentures
Root Canal
Cosmetic Dentist
Teeth Whitening
Dental Veneers
Dental Crowns & Bridges
Preventative Dentistry
Restorative Dentistry
Orthodontics
Invisalign
Dental Implants
All-on-4
New Patients
Contact Us
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