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Forest Hill 9877 3724
Tecoma 9754 2148
Glen Iris 9048 1026
Smile Place Dental
  • General
    • Initial Consultation
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You are here: Home1 / New Patient

New Patient Medical History Form

  • Please complete this form after confirming your appointment.
  • 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.
  • Will be used to send any information we store to you electronically.
  • Will be used for to send reminders.
  • Health Fund and Medicare

  • For patients covered by the Children Dental Benefits Scheme
  • White and Gold card holders Only
  • Medical Doctor (GP) Details

  • General Practice Name
  • Name of your GP
  • Medical History

  • Please enter a number less than or equal to 50.
  • Have you suffered any of the following?

  • Allergies

  • Communication

  • Privacy and Consent

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Locations

Forest Hill

249 Canterbury Road
Forest Hill 3131
03 9877 3724

Glen Iris

38 High Street
Glen Iris 3146
03 9048 1026

Tecoma

1586 Burwood Highway
Tecoma 3160
03 9754 2148

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About Us|Privacy Policy

Hours

Monday – Thursday:
9:00am–7:00pm
Friday – Saturday:
9:00am–5:00pm

*Closed on Public Holidays*

 

*clinic may close early if bookings are not made in advance.
**Appointments after 3 pm on Saturdays are reserved for emergency and may incur a $50 surcharge.

 

Forest Hill

249 Canterbury Road
Forest Hill 3131
03 9877 3724
foresthill@smileplace.com.au

 

More Info
Tecoma

1586 Burwood Highway
Tecoma 3160
03 9754 2148
tecoma@smileplace.com.au

 

More Info
Glen Iris

38 High Street
Glen Iris 3146
03 9048 1026
gleniris@smileplace.com.au

 

More Info
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