New Patient – Smile Place Dental

Please complete this form after confirming your appointment.

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

Please make sure you enter the correct values. Some browsers like Safari and Chrome's Autofill feature will sometimes automatically enter incorrect information into the fields. Please check before submitting.

Title

First Name*

Last Name*

Preferred Name

Gender*

Female
Male
Other

Gender

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

Work 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

For patients covered by the Children Dental Benefits Scheme

Medicare Reference

Medicare Expiry Date

Department of Veterans Affairs Number

White and Gold card holders Only

Medical Doctor (GP) Details

General Practice*

General Practice Name

General Practioner

Name of your GP

General Practitioner Contact Number

GP's Address

GP's Suburb

GP's Post Code

GP's State

Medical History

Are you taking any medication?*

No
Yes

Medication Currently Taken

Medications for Osteoporosis /Bone Cancer Eg. Bisphosphonates?*

No
Yes

List Medications

Infections for bone disease?*

No
Yes

Infections for bone disease details:

Do you smoke?*

No
Yes

Have you had a joint replacement surgery?*

No
Yes

When was the joint replacement surgery?*

Are you taking any antibiotics for your joint replacement surgery?*

No
Yes

Previous history of head and neck radiation therapy?*

No
Yes

Are you pregnant?*

No
Yes

How many weeks?

Please enter a number less than or equal to 50.

Are you on contraceptive medicine?*

No
Yes

Which one? (If known)

Have you suffered any of the following?

Conditions*

Have you got any other important health issues?*

No
Yes

Please Specify any other health issues*

Allergies

Do you have any allergies to food, materials or medications?*

No
Yes

Please specify any allergies*

Communication

How did you hear about us?*

Family or friend
Online Search
GP or Specialist
Football Club
Other

Sporting Club or Other?

Do you wish to receive SMS reminders on your mobile phone?*

Yes
No

Privacy and Consent

I have read, understood and agree to the above terms.*

I agree, I have read and understood the information above

I authorise the use of the images and videos of x-rays of my face, jaws and teeth both before, during and after my treatment in a practice portfolio to showcase examples of dental work to other patients and my identity will remain anonymous.*

Yes
No

I authorise the use of my images and videos taken of my face, jaw and teeth to be used for marketing material, including websites and printed materials. I understand that if the photographs and/or videos are used, my identity will remain anonymous.*