Patient Information

Next of Kin

In case of an emergency whom should we contact?
Please indicate if different to next of kin.

Reminder System

We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.

Dental History

How long is it since your last thorough dental examination?:

Please tick any dental concerns you have?

Medical History

How do you rate your general health?
Have you had or are you suffering from any of these? (please tick)
Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify):
What medications including natural remedies are you taking?

How did you hear about us?

Referral Source

Keep Informed

To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.

Consent for Services

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.