First Name
Last Name
Gender
Date of Birth
Occupation
Home Address
Suburb
State
Post Code
Home Phone
Mobile Number
Email
Who Can We Thank For Referring You?
Medicare Number
Have You Got Private Health Insurance With Dental Cover?
Contact Name
Phone
Please select below options to indicate if you have had any of the following:
Heart ConditionArtificial Heart ValvePace MakerStrokeAsthmaCOPDDiabetes High or Low Blood PressureOsteoporosisOsteoarthritisAnaemiaTuberculosisNervous ProblemsHepatitis A B CRheumatic FeverExcessive BleedingEpilepsyThyroid ProblemsKidneyLiver Disease HIV/AIDSChemical dependencyCortisone treatmentCancerRadiotherapyChemotherapy
Have you visited GP recently?
—Please choose an option—YesNo
Do you have or have you had any disease, condition not listed previously?
Please list any known ALLERGIES (latex, penicillin, anaesthetics, aspirin, iodine, codeine, etc.)
Are you taking any MEDICINES?
Are you Pregnant?
Are you a Smoker?
Reason for today’s visit?
Date of last dental x‐rays:
Please select to indicate if you have any of the following:
Bad breathBleeding gumsBlister of lips or mouthDry MouthFinger nail bitingGrinding teethSwollen or bleeding gumsLip, cheek bitingLoose teethBroken FillingsMouth BreathingMouth painOrthodontist treatmentPain around the earPeriodontal TreatmentSensitivity to: hot/cold/sweet/on bitingSores or growth in your mouthHeadachesNeck pain
Dental Treatment Received:
CleaningFillingsGum TreatmentCrown (Cap)Root CanalFalse TeethImplantPeriodontal treatment
Are you happy with your smile?
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:
Promotion
Newsletters
Appointment reminders
Please leave this field empty.
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