Patient Registration & Medical History

Welcome! Please take a few minutes to complete this form before your appointment. Your information helps us provide you with the safest, most personalised care possible. Everything you share is strictly confidential.

Section 1 — Personal Information

What's your full name?

Date of birth:

Phone number:

Email address:

Emergency contact name:

Emergency contact phone:

Section 2 — Medical History

Please tick any conditions that apply to you:

Heart disease

Diabetes

High blood pressure

Asthma

Bleeding disorders

HIV / Hepatitis

Epilepsy

Pregnancy

None of the above

Current medications (list all, including supplements):

Section 3 — Allergies

Do you have any known allergies? Tick all that apply:

Penicillin

Latex

Anaesthesia

Aspirin

Iodine

None known

Please describe your allergies and any reactions you have experienced:

Section 4 — Your Dental Background

When was your last dental visit?

What's the main reason for your visit today?

Section 5 — Dental Anxiety

It's completely okay to feel nervous. Letting us know helps us look after you better. How would you describe your anxiety level around dental visits?

No anxiety

Mild

Moderate

Severe

Section 6 — Insurance

Insurance provider:

Please upload a photo of your insurance card:

Thank you for completing your registration. We look forward to welcoming you and making sure you're comfortable throughout your visit.