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Call Us On: 9740 3644

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- Update Your Details
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Home
New Patients
Patient forms
- New Patient Form
- Update Your Details
Services
Our Team
Health Funds

Home
New Patients
Patient forms
- New Patient Form
- Update Your Details
Services
Our Team
Health Funds

Home
New Patients
Patient forms
- New Patient Form
- Update Your Details
Services
Our Team
Health Funds

Update your details

Thank you for connecting with us. We will respond to you shortly.

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Please Enter Your Details Below

*Surname

*First Name

*Date Of Birth

*Street Address

*Suburb

*Postcode

Preferred Contact Number

Home Phone

Business Phone

Mobile Phone

Home Phone

Business / Work Phone

Mobile Phone

*Email

Employer

Occupation

Emergency contact Information

Emergency contact

Relation of Your emergency contact

Emergency contact Phone Number

Do you have Private Health Cover for Dental:

Yes

No

Name of Health Fund

Person Responsible For This Account

Confidential Medical History

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

Rheumatic Fever

Diabetes Type 1/2

Blood Disorder

Osteoporosis

HIV/Hepatitis A B C

Kidney disease

Asthma

Nervous Disorders

Epilepsy

Malaria

Angina

A stroke

High/Low Blood Pressure

High/Low Cholesterol

Have You Been Treated For Cancer?

Yes

No

Year Of Cancer Treatment?

Do You Smoke?

Yes

No

If So How Many Per Day?

Allergies

Do You Have Any Drug Allergies?

Yes

No

Latex Allergy?

Yes

No

Other Allegies (Please List)

Are You Taking Any Medications?

Yes

No

If Yes, Please List

Are You Receiving Any Medical Treatments?

Yes

No

If Yes, Please List

Have you had an unfavourable reaction to local anaesthetics?

Yes

No

Name Of Medical Practitioner

Phone Of Medical Practitioner

Pregnancy

Are You, or is there any possibility that you are pregnant?

Yes

No

Due Date

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.

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Address

Suite 2
17 Macedon Street
Sunbury 3429

Contact Us

Phone: (03) 9740 3644
Book Now
Contact Us

Appointment Hours

Monday 8-5.30
Tuesday 8-6.00
Wednesday 8-7.00
Thursday 8-6.00
Friday 8-1.00

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