Skip to content
reception@earlwooddentalcare.com.au
(02) 9559 2930
Facebook
Instagram
YouTube
Book Your Appointment
Earlwood Dental Care
Earlwood Dental Care
Home
About
Our Team
Services
Family Dentistry
Cosmetic Dentistry
Wisdom Tooth Removal
Invisible Teeth Straightening
Dental Implants
Skin Rejuvenation
Zoom Teeth Whitening
Emergency Dental
Root Canal Therapy
Myobrace
Payment Options
Smile Gallery
Specials
Blog
Contact
Home
About
Our Team
Services
Family Dentistry
Cosmetic Dentistry
Wisdom Tooth Removal
Invisible Teeth Straightening
Dental Implants
Skin Rejuvenation
Zoom Teeth Whitening
Emergency Dental
Root Canal Therapy
Myobrace
Payment Options
Smile Gallery
Specials
Blog
Contact
New Patient Form
Please enable JavaScript in your browser to complete this form.
PATIENT INFORMATION
First Name
*
Surname
*
E-mail Address
*
Address
*
Address Line 1
City
State / Province / Region
Postal Code
Home Number
Mobile Number
*
DOB
*
Occupation
Do you have dental insurance?
*
Yes
No
Health Fund Name
Card Number
Member Number
EMERGENCY CONTACT
Name
*
Relation to patient
*
Address
Address Line 1
City
State / Province / Region
Postal Code
Phone
*
DENTAL HISTORY
Please tick if you have had problems with any of the following:
Bad Breath
Food collection between the teeth
Periodental treatment
Sensitivity to sweets
Bleeding gums
Grinding teeth
Sensitivity to cold
Sensitivity when biting
Clicking or popping of the jaw
Loose teeth or broken fillings
Sensitivity to heat
Sores in mouth
How happy are you with the appearance of your smile? (1 = Not happy 10 = Very happy)
Selected Value:
1
Are you interested in: (Select all that apply)
Straightening your teeth
Teeth Whitening
Replacing a missing tooth
Skin Rejuvenation
MEDICAL HISTORY
Who is your current doctor(GP)?
Do you have or have you had any of the following?
Anemia
Athritis
Asthma
Artificial Joints
Botox (muscle relaxant injections)
Back Problems
Bleeding Disorder
Blood Disease
Cancer
Chemotherapy
Diabetes
Epilepsy
Fainting
Gastric Ulcer
High Blood Pessure
HIV/AIDS
Headaches
Heart Problems
Hepatitis
Jaw Pain
Kidney Disease
Liver Disease
Osteoperosis
Pacemaker
Respiratory Disease
Radiation Treatment
Rheumatic Fever
Reflux
Stroke
Surgery
Thyroid Problems
Tuberculosis
Venereal Disease
List medications you are currently taking:
Allergies:
Do you smoke?
Yes
No
Are you pregnant or breastfeeding?
Yes
No
Who can we thank for referring you?
How did you hear about us?
Google
BUPA
Signage
Facebook/Instagram
I agree that the above is a true and accurate record. I understand that Earlwood Dental Care requires payment on the day of treatment. Any expenses, costs or disbursements incurred by Earlwood Dental Care in recovering outstanding monies including debt collection fees and solicitor costs shall be paid by the responsible party above. I further acknowledge that failure to attend any appointments or cancellations within 24 hours will incur a fee of $100.
Website
Submit
