How did you find out about us?

First Name/s*

Last Name*

Date of Birth*

Address*

Street Address Address Line 2 City State Post Code

Postal Address

Same as above

Postal Address

Street Address Address Line 2 City State Post Code

Home Telephone

Mobile Telephone*

Email Address*

Preferred method of courtesy reminders*

How would you like us to contact you to confirm appointment times?

Emergency Contact Name

Emergency Contact Number

Health Insurance*

What health fund are you with for "Extras Cover" that entitles you to claim rebates for allied health services.

More about you

At Smile Central, we strive to provide you with the most comfortable dental experiences possible. Please take 2-3 minutes to consider and share your likes and dislikes about dental care so we can be accomodating each and every time you visit us.

Briefly, why are you looking for a new dentist?

Finding a dentist you feel comfortable with and who is easy to relate to is a very important aspect of personalised dental care. Smile Central is a private practice with traditional values and modern skills. You will always be seen by the same dentist, each and every time. Our generous appointment times allow Dr Chris Lauf extra time to be informative and friendly so you don't feel rushed or left wondering about any stage.

How may dentists have you seen in the past 5 years?

At Smile Central, we understand that visiting the dentist can be nerve racking. We especially cater for children and the most anxious of adults. So we can tailor our approach to your needs, please indicate how you have felt in the past about dental visits.

Of all the dental practices you have visited in the past, what did you like the best?

Of all the dental practices you have visited in the past, what did you like the least?

What do you wish previous dentists did differently?

Generally, what are your feelings about receiving dental treatment?

What can we do to make your visit more pleasant?

If there is anything that would make you feel more comfortable, please let us know! We understand dental treatment can be daunting at times and would like to help you overcome this.

Are you interested in changing the overall look of your smile with cosmetic dental options?

Yes, please tell me more about a Smile makeover
No thank you, I just want healthy teeth
Not sure, what are my options?

What dental matters would you like to know more about?

Medical History

Is your doctor treating you at present?*

Yes
No

Details

What medical condition is your GP doctor currently treating you for or observing?

Are you taking any tablets or medicines at present?*

Yes
No

Do you take any blood thinners?

Yes
No
Unsure

Details

Please list all medications that you take regularly including prescribed medications, vitamin supplements and over the counter products for your health.

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

Yes
No

Details

Reason for why you were hospitalised?

Have you ever received any dermal therapies such as as botox, dermal fillers or similar products for your facial skin?

Yes
No

Do you smoke?*

Yes
No

Details

Please indicate how many years you have smoked for and quantity per day on average you now currently smoke. This includes liquid vapours.

Do you normally require antibiotic cover before dental treatment?*

Yes
No
Unsure

Antibiotics before dental treatment is recommended for: - some people who suffer from specific medical and heart conditions to prevent Infective Endocarditis, and/or - those who have had joint replacement surgeries within the last 3 months such as (hip or knee) to prevent Bacteraemia infections.

Details

Who is your medical practitioner?*

Contact number

Any known ALLERGIES?

Please list anything you are allergic to including though not limited to; drugs, medicines, foods, latex etc.

Please tick any of the following health conditions that have EVER applied to you*

Details of any other medical conditions

If pregnant, when are you due?

Please list any problems or medical complications you have had with previous dental treatment

If you have visited a dentist in the past 2 years, would you like to request that your records including dental x-rays be transferred to us ?

Yes
No
unsure

I have completed this form to the best of my knowledge and acknowledge that this information is an accurate account of my medical history. I understand that failure to do so may compromise my health. On future visits I will advise the dental practitioner of any changes.

I acknowledge that by signing this form I have agreed to pay all fees in full at the time of each appointment*

Yes
No
I would like to arrange a payment plan

As an independant private dental practice; we accept all major health funds, have EFTPOS and credit card facilities and happy to offer payment plans by request if prearranged.

Date

Signature*

(Parent/Guardian if under 18 years)

Thank you for taking the time to complete this form, we will be with you shortly.

Comments

This field is for validation purposes and should be left unchanged.

Smile Central New Patient Questionnaire

More about you

Medical History

I have completed this form to the best of my knowledge and acknowledge that this information is an accurate account of my medical history. I understand that failure to do so may compromise my health. On future visits I will advise the dental practitioner of any changes.

Thank you for taking the time to complete this form, we will be with you shortly.