New Patient

Smile Place clinic location for your appointment.*

Forest Hill

Glen Iris

Tecoma

Are you completing this form on behalf of a dependent?*

No

Yes

Name of person completing form

The person completing this form on behalf of a dependent is responsible for validity of the information on this form.

Patient Information

Title*

Gender*

Gender

First Name*

Last Name*

Preferred Name

Date of Birth*

Email*

Will be used to send any information we store to you electronically.

Mobile Contact Number*

Will be used for to send reminders.

Home Contact Number

Office Contact Number

Street Address*

Suburb*

Post Code*

State*

Occupation

Emergency Contact

Emergency Contact Number*

Health Fund and Medicare

Health Fund

Health Fund Membership Number

Health Fund Reference Number

Medicare Number

Medicare Reference

Medicare Expiry Date

For patients covered by the Children Dental Benefits Scheme

Department of Veterans Affairs Number

White and Gold card holders Only

Medical Doctor (GP) Details

General Practice*

General Practioner

General Practitioner Contact Number

GP's Address

GP's Suburb

GP's Post Code

GP's State

New Patient Medical History Form

Patient Information

Health Fund and Medicare

Medical Doctor (GP) Details

Medical History

Communication

Privacy and Consent