Microsoft word - glenferrie dental - new patients form.doc
This form will help us provide you with dental care of the highest standard.
All information will remain strictly confidential and is protected by Federal
Ms / Mrs / Miss / Mr / Dr / Prof / Other: ……………………
Family Name: …………………………………….
First name: ……………………………. Preferred name: …………………………. Date of Birth: …………
Home Address: …………………………………………………………………………………………….
Postal Address (if different to above): ………………………………………………………………………….
Business Address: ………………………………………………………………………………………….
Phone No. : Home: ………………………… Work: ……………………… Mobile: ……………………….
How would you like us to contact you? (Please circle): Home/Work/Mobile/Any
Email: ………………………………………………………………………………………………………
Occupation: ………………………………………
Dental Insurance: YES / NO Which fund ? : …………….
Emergency Contact: Name: …………………………………….…… Phone No. : ………………………….
How did you hear about us? ………………………………………………………………………………….
MEDICAL HISTORY Please tick ONLY those that apply to you:
Do you have any allergies? YES / NO Please specify: ………………………………………………………….
List all tablets / medicines etc. you currently take: ……………………………………………………………….
…………………………………………………………………………………………………………….
Do you have a heart murmur, pacemaker, artificial heart valves or artificial joints?
Do you require antibiotics before dental treatment, now, or in the past?
Are you taking Fosamax (or any other medication) to combat osteoporosis?
Would you like to discuss these questions in private with the dentist?
PLEASE TURN OVER
Your Medical Doctor (Clinic)’s Name: …………………………………………. Phone No. : …………………
DENTAL HISTORY
Is there anything in particular you wish to discuss with us today? Please briefly describe.
……………………………………………………………………………………………………….
……………………………………………………………………………….………………………
Do you have any concerns about previous dental treatment you would like to discuss?
Please tick ONLY those that apply to you:
In the last month have you had any pain in your mouth?
Do your gums bleed when you brush or floss?
Does floss catch or shred in some places?
Does food regularly lodge between particular teeth?
Are your teeth sensitive to temperature or brushing?
Do you have a tooth / teeth which look darker than the others?
Does a gap or missing teeth force you to chew mostly on only one side?
…or make it harder to chew some foods?
Do you have a denture you wish you didn’t have to wear?
Do you suffer recurrent headaches? Many headaches can be relieved by
Do you wake with a sore or ‘tired’ jaw?
Do you have worn, chipped or uneven tooth edges that bother you
Do you have spaces or ‘gaps’ but wish you didn’t?
Do you have old fillings or other dental work that cause you discomfort or you
How would you rate your smile on a scale of 1 – 10 …………….
How would you improve your smile? (Please circle): Improve tooth shape / Change
I understand I am personally responsible for all dental services rendered and acknowledge
and expected on the day of treatment. In the event of non-payment you agree to us sending
Signed:……………………………………………………… Date:……………………………
NB: For under 18s, this form must be signed by a Parent / Guardian. Thank you.
Glenferrie Dental www.glenferriedental.com.au
moxis in Eastern Europe (pp. 293-415). As a matter of fact, the first footnote of the volume already announces a French version of Dan Dana’s book, Les métamorphoses de Mircea Eliade : À partir du motif de Zalmoxis, in preparation at Galaade Publishing House (Paris). The points of contention raised herein do not subtract at all from a rare historiographic achie-vement in which the mysterio
March 2013 Dear Families, Riverview’s Health Care Center welcomes our new and returning students for the 2012- 2013 school year. In preparation, you will find the paperwork that needs to be completed prior to enrollment in the summer and/or fall program. This must be done annually and, therefore, includes returning students. As required by the Commonwealth of Massachusetts, the Departme