New Patient Medical and Dental History

Prior to filling the forms, please take a moment to read the information below and help us keep our community safe:

If you have answered yes to any of the above, please notify our staff immediately.

Given name

Surname

Preferred name

Date of Birth

Residential Address

Postal Address (if different)

Mobile

Home Phone

Work Phone

Email

Occupation

Emergency Contact

Phone

Relation

Private Health Insurer

Member No.

Patient No.

Veterans’ Affair

Expiry

GP Name and Clinic

GP Phone

Medical History

If yes, how many weeks?

Are you taking medication (including natural supplements)? If yes, please list:

If yes, how many per day?

Do you suffer from dental anxiety?

Dental History

Last dental visit:

If yes, please detail:

Is there anything else your dentist should be aware of?

Privacy Policy:

All personal information collected by Pyramid Family Dental is handled in accordance with our privacy policy. By signing this form you hereby agree and acknowledge that: (i) you have accurately completed this new patient/medical history form to the best of your knowledge; (ii) you consent to any treatment agreed upon, to be carried out by the dentists and their staff; (iii) you are responsible for payment of all services rendered on your behalf and on behalf of your dependents; (iv) payment is due at the time of service unless other arrangements have been made; and (v) your dentist may take images of your teeth both before and after your treatment and details will remain confidential. PLEASE NOTE: If you are unable to attend your appointment, please let us know at your earliest convenience so we can offer your booking to someone else. If you do not attend an afternoon appointment (3pm onwards) on a weekday or anytime on a Saturday and you fail to let us know, we will be unable to book the same time slot for you for 6 months.

Patient print name (or parent/guardian if patient is under 18)

Date