0296378077 [email protected]

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SMILE GALLERY
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NEW PATIENT FORM

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New Patient Form

Patient Information

Full Name *

First

Last

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Gender *

Marital Status

Date of Birth *

Occupation

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Phone Number *

Email Address *

Alternate Phone *

Home Address *

Address Line 1

City

State / Province / Region

Postal Code

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Emergency Contact Name

Emergency Contact Number *

How did you hear about us? *

Medical Information

Do you have private health insurance? *

Health fund provider *

Member Number *

Have you ever had or are you suffering from *

Diabetes
Heart disease
High blood pressure
Excessive bleeding
Rheumatic Fever
Artificial Valves/prostheses
Heart Murmur
Prolonged Bleeding
Gastric Problems
Arthritis
Osteoporosis
Eating Disorder
Sleep Apnoea
Asthma
Hepatitis
HIV/AIDS positive
None of the above

Please check all that apply

Are you a smoker ? *

Do you require antibiotic therapy for any condition prior to undergoing dental treatment? *

Are you at currently taking any drugs, medicines, having injections or attending a doctor? *

Are you allergic to any food, drugs or antiseptics (especially penicillin) *

Have you had any other serious illnesses or accidents in the past? *

Are you pregnant ? *

Please state how many months *

Name of your GP

GP's Clinic name/ Address

Dental Information

How long has it been since your last dental checkup? *

Are your teeth sensitive to cold drinks? *

Do your gums bleed when you brush your teeth? *

Did you ever have an injury to face, teeth or jaws ? *

What is your main dental concern? *

Consent

Consent for treatment *

I consent to a complete dental check up , Xrays, intraoral photos, scans and dental treatment by the dentist.

Signature *

Date *

Dr Amtul Saba
17/254 Pitt St, Merrylands NSW 2160
Ph: 0296378077
E: [email protected]
https://beautifulsmiledentalsurgery.com.au/

Contact Us

0296378077

[email protected]

BOOK ONLINE

Opening Hours

Monday | 9am – 6pm

Tuesday | 9am – 6pm

Wednesday | Closed

Thursday | 12pm – 7pm

Friday | 12pm – 7pm

Saturday | 9am – 5pm

Sunday | Closed