New Patients Questionnaire

Personal Information

Practice Policies
  • Payment is required in full at each appointment. We accept cash, bank cheque, eftpos and credit cards.

  • You acknowledge that as a courtesy you will give us at least 2 business days notice if you need to reschedule an appointment.

  • You allow your treatment records to be utilised anonymously for teaching or educational programmes.

  • You acknowledge your records may be sent to your referring doctor/dentist/health professionals involved in your care.

I have read the privacy information provided:

*Signature on arrival.

Health Questionnaire

Are you currently receiving any medical treatment?


Have you been hospitalised for any reason in the last 2 years?


Have you had any allergies/reactions from medication, anaesthetics or latex?


Are you taking any medications or supplements at present, both prescribed or over the counter? (Please list)


Do you smoke?


Are you pregnant?



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