Preferred method of contact
Email Text Home phone Work phone
(From time to time we may forward information by email. Please let us know if you do not wish to be included in this.)
Date of birth
Name of last dentist
Person who referred you, or the source of your learning of us:
If under 20, name & address of Parent/Guardian
Name of medical practitioner
If you are attending school, which school do you attend?
CONFIDENTIAL HEALTH QUESTIONNAIRE
In order to provide the best and safest dental treatment, your dentist needs to know of any medical problems which may affect your treatment. Please see the health information consent section at the end of this document.
1. Are you receiving any medical treatment at the present time?
2. Have you been a patient in hospital during the past 2 years?
3. Tick any of the following which you have had:
If you get severe headaches, how often?
Are you apprehensive of Dental Treatment?
4. Are you taking any tablets, capsules, medicines or drugs?
If yes, please list:
5. Have you had any allergies to medicines that you are aware of?
5. If yes, please list
6. Have you had any prosthetic surgery? (eg heart valve or hip replacement)
7. Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?
8. Have you ever had contact with the HIV virus or Hepatitis B virus?
9. Have you ever had a reaction to an anaesthetic?
10. Women - are you pregnant now?
If you are pregnant, how many months?
11. Is there any family history of diabetes?
Are there any other aspects concerning your health that you think your dentist should know about?
Comments or additional information
If you would please respond to the questions below, it will help us to help you more
1. Do you like the appearance of your teeth and your smile?
2. Are your teeth all in alignment (straight)?
3. Do you have spaces that you don't like?
4. Do you like the colour of your teeth?
5. Do you like the shape of your teeth?
6. Are your teeth chipped, protuding or hidden?
7. Are there old fillings or dental work that you don't like looking at?
8. What would you most like to change or improve in the appearance of your teeth?
Thank you for choosing us as your dental health care provider. To maintain the practice operation and prevent potential misunderstanding, we ask patients to adhere to the financial arran gements regarding their treatment. Payment is required at the time services are rendered. We can offer extended payment for some treatments, please ask our staff for details prior to commencing treatment. Overdue accounts will incur fees. Fees also apply for broken appointments without proper notification.
I consent to North Shore Dental collecting and keeping information about my health for the purpose of making sure that I receive appropriate care and treatment, and for associated administrative tasks. I understand my relevant health information will be stored by North Shore Dental, and that I am entitled to request access to and correction of my health information. I agree to provide this information voluntarily.
I understand and agree with the above financial and health information policies
At North Shore Dental we want to make your experience as relaxed and comfortable as possible as we all know that coming to the dentist isnt your favourite place to be.
To ensure your visits with us are the most pleasant please tick any of the following that may apply to you:
Or tell us something else about how you feel: