(03) 9740 3644
|
admin@designdentalgroup.com.au
Call Us On: 9740 3644
Book Now

Update your details

    *Surname

    *First Name

    *Date Of Birth

    *Street Address

    *Suburb

    *Postcode

    *Email

    Preferred Contact Number

    Home Phone

    Business / Work Phone

    Mobile Phone

    Employer

    Occupation

    Emergency Contact Information

    Emergency Contact

    Relation of Your Emergency Contact

    Emergency Contact Phone Number

    Do you have Private Health Cover for Dental?

    Name of Health Fund

    Person Responsible For This Account

    Confidential Medical History
    To the best of your knowledge do you have, or have you suffered from the following?

    Have You Been Treated For Cancer?

    Year Of Cancer Treatment?

    Do You Smoke?

    If So How Many Per Day?

    Allergies

    Do You Have Any Drug Allergies?

    Latex Allergy?

    Other Allergies (Please List)

    Medications & Treatments

    Are You Taking Any Medications?

    If Yes, Please List

    Are You Receiving Any Medical Treatments?

    If Yes, Please List

    Have you had an unfavourable reaction to local anaesthetics?

    Name Of Medical Practitioner

    Phone Of Medical Practitioner

    Pregnancy

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

    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.