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Please note that any information provided will remain STRICTLY CONFIDENTIAL.

Your main reason for attending our dental centre
Patient Information
Surname:* Title:*
Given Name(s):* Date of Birth:
Ph (home):* Ph (work):
Mobile number: E-mail:*
Home Address:
Postcode:* Occupation:

Note: If the patient is a minor please note below the name of the parent or guardian completing this:
Surname: Title:
Given Name(s): Phone:
Referral Information
Whom may we thank for referring you to our practice?
Name of the person
If not a direct referral, how you heard about Sydney Holistic Dental Centre:
Dental History
Teeth feel sensitive to:
Jaw has locked:
How often How long has this gone on
How often How long has this gone on
 
How often How long has this gone on
 
   
Are you happy with
   
Would you like an explanation about tooth whitening
Would you like an explanation regarding fresh breath therapy?
Would you like an explanation about our snoring appliance?
How long since your last dental visit?
Would you describe yourself as a relaxed dental patient?
Have you seen or are you aware of Dental Hygienists?
Is there anything about previous dental experiences you`d like us to know?
Medical History
     
Other conditions
Approximately when was your last medical check up

Are you currently seeing a health professional for any health problems?
If you would like us to inform your GP or other health professional(s) of your treatment with us as it relates to your general health, please include the name of these practitioners
Are you taking any medications or supplements?
Are you allergic to anything?
Consent for Services

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Any surgical or invasive procedure carries risks. Before proceeding with a surgical or invasive procedure, you should seek a second opinion from an appropriately qualified health practitioner.
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