03 9826 172503 9826 8240
627 Malvern Road, Toorak 3142
To use the online patient form, please visit this page on your computer.
In case of an emergency whom should we contact?
Please indicate if different to next of kin.
We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.
Have you had or are you suffering from any of these? (please tick)
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.