New Patient Registration - A Better Smile

Dr J. Kligman • Dr A. Navas • Dr P. Vukasin • Dr M. Sahid

76 Burns Bay Road, Lane Cove. NSW 2066
94273366 - 94186499

Suite 8, level 2/64 Castlereagh St, Sydney. NSW 2000
92300140

New patient registration form

Welcome to A Better Smile Dental Centre. In order to provide the best possible dental care it is important to have the following information, which will be handled with the utmost confidentiality and will not pass beyond this practice without your written consent.

Please notify us promptly of any changes in your contact details. Accurate contact details help us identify you and your dental records.

Confidential Information

Treatment *

Dr
Mr
Mrs
Miss
Master

Surname *

First Name *

Preferred Name

Date of Birth *

Address

Suburb

Post Code

Home Phone *

Business Phone

Mobile

Email *

Occupation

Emergency Contact *

Mobile of Emergency Contact *

Last dental visit

Medical practitioner

Confidential Medical History

Have you ever had any of the following?

Rheumatic fever
Asthma
Heart Ailments
Diabetes
Epilepsy
Stroke
Hepatitis B
Malaria
High blood pressure
Hepatitis A or C
Angina
Low Blood Pressure
Nervous disorders
Kidney disease
Blood disorders
Depression
HIV
Joint replacements

Do you have any drug allergies? *

If yes, please name it

Are you currently receiving any medical treatment? *

If yes, please name it

Are you currently taking any medications? *

If yes, please name it

Have you ever reacted to local anaesthetics? *

If yes, please name it

(Ladies) Is there any possibility you may be pregnant?

How did you hear about our practice?

Google
Facebook
Instagram
Referral

If someone referred us, who should we thank for the referral?

I agree to dental treatment & take full responsibility for payment of my account (or the above-named minor who is under my care)

Signature *

You can use your mouse (or touch screen) to create a digital representation of your actual signature

Date