New Patient Registration at Tawa Dental Care

Name(Required)

Prefix First Names Surnames

Date of Birth(Required)

How did you hear about us?

Address(Required)

Address Postcode

Mobile Phone(Required)

Work Phone

Email(Required)

Occupation(Required)

Employer(Required)

Person Financially Responsible (if not self)(Required)

Emergency Contact & Relationship(Required)

Emergency Contact Phone Number(Required)

Purpose of Today's Visit(Required)

Is another member of your family a patient at our office?(Required)

Yes

Do you have Southern Cross dental coverage?(Required)

Yes

Oral Health Questionaire

How often do you brush your teeth?(Required)

How often do you floss your teeth?(Required)

Do you usually use a manual or electric toothbrush?(Required)

Manual

Electric

Do you use a hard, medium or soft bristle brush?(Required)

Hard

Medium

Soft

Does it have a pressure sensor?(Required)

Yes

What brand of toothpaste do you use?(Required)

After brushing, do you rinse your mouth with water or only spit out the excess toothpaste?(Required)

Health Questionaire

Please tick all that apply

Please select all that apply

Please select all that apply 2

What type of Hepatitis

Any Other Health Concerns

Are you Pregnant

Yes

Due Date

Are you taking any tablets, capsules, medicines or drugs?(Required)

Yes

If Yes, Please List?(Required)

Are you aware of any allergies?(Required)

Yes

If Yes, Please List?(Required)

Please answer the following questions below:

Does your jaw "click" or hurt?(Required)

Yes

Do you feel you grind or clench your teeth?(Required)

Yes

Does floss ever tear between your teeth?(Required)

Yes

Does food get jammed between your teeth?(Required)

Yes

Do you think you have bad breath?(Required)

Yes

Do your gums bleed when you clean your teeth?(Required)

Yes

Have you ever had periodontal (gum) treatment?(Required)

Yes

Do you experience sensitivity with hot or cold?(Required)

Yes

Do your teeth ever hurt when you bite hard?(Required)

Yes

Do you have any broken teeth or fillings?(Required)

Yes

Do you have any gaps in your teeth you would like to address?(Required)

Yes

Do you consider keeping your teeth for a lifetime important?(Required)

Yes

Are you interested in whitening your teeth?(Required)

Yes

Name and place of Medical Practitioner (GP)(Required)

Previous Dental Practice

When was your last dental appointment?

Reason for previous dental visit

Are you feeling nervous about your dental treatment?

Yes

What is your main concern?

Is there anything else you'd like to share with us?

Consent for Treatment

1. I hereby authorise the dentist or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.
2. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
3. I agree to the use of anaesthetics, and other medication as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand I can ask for a complete recital of any possible complications.
4. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. I understand that any overdue accounts will incur a $10.00 monthly account fee and interest at 2% per month. I agree to be responsible for all fees incurred in the collection of any monies owed to Tawa Dental Care.

Signature

New Patient Registration