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Burnside Dental Family Dentist

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- New Patient Form

New Patient Form

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New Patient Form

Welcome to Burnside Dental Practice

Please take time to answer these questions. It will assist us in providing the best care for you.

Medical History

Please tick a box if you have ever suffered from any of the following conditions;

Heart Murmur

Yes No

Heart/Vascular Disorder

Yes No

Rheumatic Fever

Yes No

Blood Pressure Problems

Yes No

Diabetes

Yes No

Epilepsy

Yes No

Asthma

Yes No

Liver or Kidney Disease

Yes No

Hepatitis

Yes No

Excessive Bleeding

Yes No

Are you a smoker

Yes No

Allergies

Yes No

Are you Pregnant?

Yes No

Have you had any recent Surgery/Illness? (eg.hip replacements)

Yes No

Do you consume wine or sports drinks (ie Gatorade) on a regular basis?

Yes No

Do you suffer from any illness/condition not listed? (eg.Osteoporosis, Depression/Anxiety)

Yes No

Do you take drugs or prescribed medicine regularly? (eg. Aspirin)

Yes No

Home Address

Work Address

Dental History

Are you concerned about any of the following?

Bad Breath

Yes No

Mouth Ulcers

Yes No

Mouth Dryness

Yes No

Sensitive Teeth

Yes No

Bleeding Gums

Yes No

Chewing Difficulties

Yes No

Loose Teeth

Yes No

Headaches

Yes No

Sore Tongue, Throat, Palate

Yes No

Facial Pain, Ear Ache

Yes No

Gagging

Yes No

Snoring / Sleep Aponea

Yes No

Have you had Dental X-Rays in the last two years?

Yes No

I understand that payment of the account is my responsibility and that accounts are to be finalised at every appointment. I undertake to pay any additional expenses, including debt collection agencies and legal costs incurred in recovering overdue accounts.

Please Note: Your appointment is reserved exclusively for you. Cancellations of less than 48 hours notice may incur a fee.