Patient Forms | Hawthorn Dental

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NEW PATIENT FORMS

Click below to complete patient forms online or download our PDF patient forms and follow the instructions below.

ONLINE New Patient Form

ONLINE Records Release Consent

On completion of PDF forms please return via email to reception@hawthorndentalsurgery.com.au

or via our upload form link below.

PDF New Patient Form

PDF Records Release Consent

Submit Completed PDF Forms

A PDF reader is required to access these documents.

Download a free version here.

New Patient Form

NEW PATIENT FORM

Please take a moment to fill out the form.

PERSONAL DETAILS

First Name

Home Address

Last Name

Phone Number

Email

Date of Birth

Person responsible for payment

Do you have Private Health cover?

Address (if different from above)

Fund

Membership No.

Membership ID (eg 01/02/03)

DENTAL HISTORY

Did you have x-rays with your previous dentist?

Yes

No

Are you satisfied with the apperance of your teeth?

Yes

No

Have you visited your dentist regularly?

Yes

No

Have you any questions you would like answered?

Yes

No

MEDICAL HISTORY

Doctor

Dr's Phone

The following conditions have important relevance to dental treatment – please put a tick against the condition(s) you think you currently suffer from or have had previously:

Heart disorder

Fainting on injection

Rheumatic fever

Thyroid problems

Asthma

Hepatitis

Diabetes

Are you allergic to penicillin or to any other drugs?

Yes

No

Are you taking any anticoagulants? eg apixaban, clopidogrel, aspririn

Yes

No

Are you taking any other medication regularly?

Yes

No

For Females - are you pregnant?

Yes

No

Haemophilia

Epilepsy

Kidney problems

Arthritis

Blood pressure (high/low)

Radiotherapy of head/neck

Slow or complicated healing

If YES, please list

If YES, please list

If YES, please list

If YES, how many weeks?

Please let us know if there are any other conditions or problems that may be relevant to your dental treatment:

ACCOUNTS

An account will be given to you at the completion of treatment. It is anticipated payment of the account will be made on the day of treatment. Hi-caps and credit card facilities are available.

If other payment arrangements need to be made, please discuss it with our practice manager prior to the commencement of treatment.

Your Signature

Date

THANK YOU! Your form has been successfully submitted.

Patient Consent Form

PATIENT CONSENT FORM

Please take a moment to fill out the form.

First Name

Last Name

Address

Date of Birth

I,

hereby consent to

Your Signature

Date

THANK YOU! Your form has been successfully submitted.

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