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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

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.