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New Patient Form​
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New Patient Form​
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New Patient Form​

    Personal Information

    Emergency Contact Details:

    Medical History

    Please select below options to indicate if you have had any of the following:

    Please list any known ALLERGIES (latex, penicillin, anaesthetics, aspirin, iodine, codeine, etc.)

    Dental History

    Please select to indicate if you have any of the following:

    Dental Treatment Received:


    1. I,

    , have answered all questions to the best of my knowledge, and agree to notify the dentist of any changes to my health or medication. Where essential to the provision of optimal care I give consent for authorised members of this practice to seek further health history information from the relevant health care provider. I understand that my health information may be disclosed to authorise personnel where necessary for the provision of optimum care.

    2. I hereby authorise the dentist or designated staff to use all necessary diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.

    3. Upon such diagnosis, I authorise the dentist to perform all treatment mutually agreed upon by me, and to employ such assistance as required to provide proper care.

    4. I will be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service, unless financial arrangements has been agreed prior to treatment and signed by both parties.

    5. For appointments that require more than half an hour’s treatment a minimum deposit of $80 must be paid at time of booking. If appointments are cancelled with less than 24 hours’ notice, the deposit may be retained and not refunded by Smile Ville at the discretion of dentist.

    6. I understand that Smile Ville requires a minimum of 48 hours’ notice if I need to reschedule my appointment. If I do not give 24 hours’ notice of cancellation, a broken appointment fee may apply.

    7. A Consultation fee is to be paid upfront for any emergency appointments. Then payment of subsequent dentist quote after consultation will require payment prior to treatment being carried out.

    8. I consent to Smile Ville contact me for the following: