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Suite 7, The Gap Village Shopping Centre, 1000 Waterworks Rd, The Gap, QLD 4061 | P: 07 3300 5355 | E: click here

Toothbrush

Suite 7, The Gap Village Shopping Centre, 1000 Waterworks Rd, The Gap, QLD 4061
P: 07 3300 5355
E: admin@thedentist.com.au

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Hours
Monday:
8.30am - 6.00pm
Thursday:
9.00am - 8.00pm
Tue, Wed, Fri:
8.30am - 5.30pm
Saturday:
8:30am - 1.00pm

Online FormFirst time visit? Fill in our patient form online now
ParkingFree undercover parking
Wheelchair AccessEasy access for wheel chairs

New Patient Form

At Dental Excellence we strive to provide you with the highest possible care. To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present.  Without this information it is difficult for your dentist or hygienist to plan your care properly.

Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation.  If you would like any further information about how we use and protect your personal information, please ask one of our staff for our brochure “Personal Information, Privacy and your Dentist”.

Download the PDF version here.

 

Patient Information
Title:
Surname:* Given Name:*
Preferred Name: Date of Birth:*
Address:* Suburb:*
Postcode:*
Ph (home):* Mobile Number:
Ph (work):
E-mail:*
Vet Affairs Vet Affairs Card No:
VA Expiry Date:
Name of Private Health Fund (if any): Position No on Card:
Occupation: Employer Name:
Next of Kin
Name: Relationship:
Phone:

In case of an emergency whom should we contact?

Please indicate if different to next of kin.
Name: Relationship:
Phone:
Reminder System

We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.
Dental History
How long is it since your last thorough dental examination?:
Please tick any dental concerns you have?
Medical History
How do you rate your general health?
Who is your General Practitioner?:
Telephone:

Have you had or are you suffering from any of these? (please tick)
Other ( please specify):
Please list all medications and tablets you are taking?:
Are you allergic to any medicines, tablets or drugs?:
Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify):
How did you hear about us?
Referral Source:    
Keep Informed Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
Consent for Services

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.

 

 

 

Any surgical or invasive procedure carries risks. Before proceeding with a surgical or invasive procedure, you should seek a second opinion from an
appropriately qualified health practitioner.