New Patient Information

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At Dental Care Professionals, we strive to provide you with the highest possible care.

To do this we need to collect personal information from you that includes contact details and matters pertaining to your general health, both past and present.

Without this information it is difficult for your dentist or hygienist to plan your care properly.
Branch
Personal Details
Title*
First Name*
Last Name*
Date of Birth*
Gender*
Preferred Name*
Occupation*
Nationality*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone
Home*
Mobile*
Work*
Next of Kin/Emergency Contact
Name*
Relationship*
Phone*
Private Healthcare
Please provide Private Healthcare Fund as applicable. If you're not a member of a Private Health Fund, just type in "N/A".
Private Health Fund*
Card Number*
Medicare
Please provide Medicare details as applicable. If you don't have these details available, please enter "TBA" or "N/A".
Card Number*
Position*
Expires*
Enter the expiration date on your car as MM/YYYY (e.g. 05/2013)
Appointments
Preferred Appointment Contact Methods*
- SMS
- Email
- Phone
- Do not call

Medical History
Have you had or are you suffering from any of the following?
Heart/Vascular Disorder*
- Yes
- No
Please provide Heart/Vascular disorder details:
Blood Disease/Bleeder*
- Yes
- No
Please provide Blood Disease/Bleeder details:
Blood Pressure Problem*
- Yes
- No
Please provide Blood Pressure Problem details:
Rheumatic Fever*
- Yes
- No
Bone Disease (Pagets)*
- Yes
- No
Osteoporosis*
- Yes
- No
Cancer*
- Yes
- No
Please provide Cancer details
HIV/AIDS*
- Yes
- No
Hepatitis B or C*
- Yes
- No
Please provide Hepatitis details
Arthritis*
- Yes
- No
Diabetes*
- Yes
- No
Please provide Diabetes details
Liver or Kidney Disease*
- Yes
- No
Please provide Liver or Kidney Disease details
Asthma*
- Yes
- No
Epilepsy*
- Yes
- No
Please provide Epilepsy details
Nervous Disorders*
- Yes
- No
Eating Disorder*
- Yes
- No
Please provide Eating Disorder details
Sleep Apnoea*
- Yes
- No
Stomach or Digestive Condition/Reflux*
- Yes
- No
Please provide Digestive Condition details
Joint Replacement (E.g. hip/knee)*
- Yes
- No
Please provide Joint Replacement details
Other Health Problems*
- Yes
- No
Please provide details of Other Health Problems
Are you, or could you be Pregnant?*
- Yes
- No
Smoker/Previously a Smoker*
- Yes
- No
Please provide smoking details (ie: how many cigarettes per day / when did you quit)?

General Practitioner Details
Your GP's Name*
Your GP's Contact Number*
Do you have any allergies?*
- Yes
- No
Please provide details of Allergies
Cardiac Conditions
Heart surgery within the past 6 months?*
- Yes
- No
Pacemaker?*
- Yes
- No
Vascular Surgery (replaced artery) within the past 6 months?*
- Yes
- No
History of heart murmur (mitral valve prolapsed)?*
- Yes
- No
Previous bacterial endocarditis?*
- Yes
- No
Systemic pulmonary shunt?*
- Yes
- No
Congenital Heart Defect?*
- Yes
- No
Acquired valvular dysfunction?*
- Yes
- No
Artificial heart valve?*
- Yes
- No
History of rheumatic fever?*
- Yes
- No
Medications
Please list any medications (including natural remedies) you are taking:*

Dental History
How long has it been since your last dental check-up?*
- 6 months
- 1 year
- 2 years
- 3 years and longer
Please select any dental concerns you may have
- Toothache
- Sensitive Teeth
- Bleeding Gums
- Loose Teeth
- Bad Breath
- Dry Mouth
- Missing Teeth
- Unsatisfactory Denture
- Rapidly Decaying Teeth
- Lost Filling/Cavity
- Grinding/Clenching Teeth
- Worn/Broken Teeth
- Pain in Face or Jaw Joints
- Sounds from Jaw Joint
- Difficulty Chewing
- Discoloured Teeth
- Bad Appearance of Teeth
- Would you like a Whiter Smile?
How Did You Hear About Us?
Please help us help more people by letting us know how you heard about Dental Care Professionals*
- Referred by another patient
- Referred by a staff member (please specify)
- Yellow Pages Online
- Yellow Pages Online
- Radio
- Google
- Dental Care Professionals Website
- Passing by
- ADA Website
- Other (please specify)
Please provide details

I accept the ultimate responsibility for payment of all dental treatment carried out on myself, including any fees from missed appointments or appointments cancelled with less than 24 hours notice, and agree to pay all fees at the time of the appointment unless prior arrangements have been made. In default, I agree to pay all account handling fees and collection charges for overdue accounts.
- I accept the Terms and Agreements

Medicare/Bulk Billing

You may be eligible for benefits under the Child Dental Benefits Schedule.

HICAPS

Direct claiming of health fund rebates through your private health insurance.

Payment Options

Payment options to make it easier for you to receive the best treatment.

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