New patient form

Your details

Preferred contact phone: Home phoneBusiness phoneMobile phone

Do you have Private Health Cover for Dental: YesNo

Confidential Medical History

Are you or have you ever been treated for any of the following?

Do you smoke? YesNo

If yes, how many per day? 5102030

Do you have any drug allergies? YesNo

Latex allergy? YesNo

Are you currently taking any medications? YesNo

Are you currently receiving any medical treatment? YesNo

Have you had an unfavourable reaction to local anaesthetics? YesNo

Ladies, is there a possibility that you are pregnant? YesNo

Have you had problems with previous dental visits? YesNo

Do you feel that you grind your teeth? YesNo

Does your jaw click? YesNo

Do you wake with a sore/tired jaw? YesNo

Have you ever been prescribed a “night guard”? YesNo

How often do you brush your teeth? Once a dayTwice a dayThree times a day

Which type of toothbrush do you use? ManualElectric

Do your gums bleed when you clean your teeth? YesNo

Do you floss? Every daySometimesNever

Have you ever been diagnosed with Periodontal Disease? YesNo

Have you ever had your gums treated by a Dental Hygienist? YesNo

Do you have worn, uneven edges on your teeth? YesNo

If yes, do these bother you ? YesNo

Do you have chips on your teeth that bother you? YesNo

Do you have spaces that bother you? YesNo

Do you like the colour of your teeth?

How would you improve your smile?

We request and expect payment at the time of treatment.
For your convenience Design Dental Group is equipped with the "HICAPS" system and accept cash, cheques, eftpos,
and most major credit cards.