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;

Home Address

Work Address

Dental History

Are you concerned about any of the following?

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.