NEW PATIENT FORM

NEW PATIENT INFORMATION

"*" indicates required fields

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Welcome to Sydney Prosthodontic Group. Thank you for taking the time to complete the following form.

There are 3 sections and you can save your progress at any time. As a medico-legal requirement according to Dental Practice Regulations 2004 under the Dental Practice Act 2001, for us to provide correct advice and safe treatments, detailed personal and medical information is required.

All information will be treated with strictest confidentiality.

If you wish to read about our privacy policy, please click here.

Personal Information

Title*

Given Name*

Family name*

Preferred name

Date of Birth*

DD slash MM slash YYYY

Gender*

Male

Female

X (intersex / indeterminate / unspecified)

Address*

Street Address City State Post Code

Preferred method of contact*

Home

Work

Mobile

Telephone (Home)

Telephone (Work)

Mobile

Email*

Emergency Contact (Name)*

Emergency Contact (Mobile)*

Who may we thank for referring you to our practice**

If the treatment is appropriate, would you prefer to see a specialist who also speaks:

Mandarin

Cantonese

Vietnamese

Arabic

Medical Information

1. Please tick any past or current conditions or illnesses*

Anxiety

Autoimmune disorder

Arthritis

Asthma

Bleeding problem

Blood pressure problem

Chemotherapy/Radiotherapy

Cancer/tumour

Dementia

Depression

Diabetes

Dizziness/fainting

Epilepsy

Gastric reflux

Heart problem

Hepatitis B/C

HIV/AIDS

Joint replacement

Kidney problem

Liver problem

Osteoporosis

Psychiatric disorder

Rheumatic fever

Sinus problem

Sleep apnoea

Thyroid problem

Tuberculosis

Vascular problem

None of the above

Any other conditions/illnesses not listed above?

2. Have you ever received medication/injections/infusions for osteoporosis? (E.g. Fosamax, Actonel, Prolia, Aclasta, Xgeva, etc.)*

Yes

2a. How long have you been this medication/injections/infusions?*

2b. Please select your medication*

Fosamax (Plus)

Alendro

Actonel

Skelid

Aredia/Pamisol

Zometa/Aclasta

Didrocal/Didronel

Bonefos

Prolia

Xgeva

3. Do you take any medications (e.g. warfarin, aspirin), supplements (e.g. fish oil, turmeric), injections (e.g. Actonel, Prolia) or recreational drugs?*

Yes

3a. Please list all*

4. Are you allergic to anything? (e.g. penicillin, latex, aluminium)*

Yes

4a. Please list all*

5. Have you ever been told you must take antibiotics before dental treatment?*

Yes

6. Have you ever had prolonged bleeding from cuts or tooth extraction?*

Yes

7. Do you vape or smoke e-cigarette/cigarette/cigar/tobacco?*

Yes

7a. How many cigarettes do you smoke a day?**

8. Are you pregnant?*

Yes

8a. How many months pregnant are you?*

9. Is there anything else we should know medically about you which has not been included above?

Dental Information

1. What is your biggest dental problem?*

2. How long have you had this problem?

3. How many dentists/specialists have you seen about this problem?

4. What problems have you had with previous dental treatments?

6. Have you received refunds/compensation from previous treatments?

7. Is there anything else we should know prior to treating you?

Please attach any supporting radiographs, photographs and other documents here (Accepted file types: jpg, png, gif, pdf, zip. 10mb limit)

Drop files here or

Accepted file types: jpg, png, gif, pdf, zip, Max. file size: 10 MB.

Acknowledgement

Agreement*

I understand all personal and medical information gathered are kept confidential and can only be released to a third party with my prior approval.

I consent to dental examination and consultation and I/my guardian assume responsibility for the associated fees. I consent for SPG clinicians to discuss my case with my referring dentist and other relevant medical personnel in order to provide me with the best advice and management.

I consent to close up photos of my teeth without revealing my personal identity to be used for case discussions, presentations and marketing purposes.

I am aware that full payment is required at the end of each visit by cash, bank cheque, EFTPOS, Visa or MasterCard (unless alternative payment arrangement has been agreed upon prior). Personal cheques are not accepted. If I choose to transfer the funds electronically via the internet, it must be transferred at least 2 working days before my appointment and I must email an online transfer receipt to the practice so that payment can be confirmed before my appointment.

I am responsible for verifying fund availability and claiming from my private health insurance, MediCare or Department of Veterans’ Affairs. The practice is not responsible for the amount I can or cannot claim.

I understand that at least 24 hours’ notice is required to reschedule an appointment or a cancellation fee of $290 may apply for failure to do so.

I agree with the above acknowledgement and understand I am submitting an electronic version of my signature.

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