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Model-Dentistry

21 Campbell Street, Parramatta, NSW 2150

Phone: 0434765101 · Email: alexis@ozfintechsolutions.com

New Patient Registration

Personal Details

Title * First Name * Last Name * Date of Birth * Address * Postcode * Phone Mobile * Email * Health Fund

Referral and Feedback

How did you hear about us?

Will you be interested to provide us with your feedback about our surgery?

Medical & Dental History

Have you ever had heart trouble or high blood pressure?

Have you been a patient in hospital in the past 2 years?

If yes, please specify:

Are you under current medical treatment?

If yes, please specify:

Are you taking any regular drugs or medicine?

If yes, please list:

Have you had any other serious illness e.g. deep ray therapy or cancer?

If yes, please specify:

Have you ever had any of the following conditions?

Rheumatic fever Diabetes Nervous disorder Hyperthyroidism Asthma Glaucoma Anaemia Tuberculosis HIV Hepatitis Epilepsy Psychiatric treatment Strokes

Have you any known allergies to drugs (especially penicillin)?

If yes, please list:

Have you had any problems with local anaesthetic?

If yes, please specify: Women, if pregnant, state how many months? Who is your regular GP? Name

Have you ever experienced prolonged bleeding?

Are you a smoker?

Consent and Signature

By signing below, you confirm that the information provided is accurate to the best of your knowledge and consent to the collection of this information for medical purposes.

Date *

Signature *

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Thank You!

Your registration has been submitted. The team will be with you shortly.