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:

Have you returned from a COVID-19 hot spot or from overseas in the last 14 days?(Required)
Are you waiting for a COVID-19 test result?(Required)
Do you have a sore throat, cough, or other respiratory symptoms?(Required)

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

Title

How did you hear about us?

Medical History

Please check any medical conditions you have

Women - Are you pregnant?
Are you a smoker?
Do you snore?
When you wake up in the morning, do you mostly feel:
Allergies

Dental History

Have you ever had a reaction or complication following dental treatment in the past?
Are you suffering from any of the following?
Are you suffering from any of the following?
Are you suffering from any of the following?
Would you like to receive a courtesy reminder for your appointment:

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.
Consent
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