NEW PATIENT FORM

All new patients at Stellar Dental are required to fill out a new patient form. Save time by filling out this form online before your first appointment.

BASIC DETAILS

CONTACT DETAILS

HOME ADDRESS

BUSINESS ADDRESS

POSTAL ADDRESS

Only fill out if different to your home address above.

EMERGENCY CONTACT

Who do we contact in case of emergency? Usually this is next of kin.

MEDICAL DOCTOR

Please provide details for your current GP.

DENTAL HISTORY

Do you have the following?

Toothache

Sensitive Teeth

Bleeding Gums

Loose Teeth

Unsatisfactory Dentures

Rapidly Decaying Teeth

Lost Filling Cavity

Grinding/Clenching of Teeth

Worn/Broken Teeth

Sounds/Clicking From Jaw

Difficulty/Discomfort when Chewing

Discoloured Teeth/Fillings

Bad Breath

GENERAL MEDICAL ISSUES

Have you ever had any of the following? Please choose 'Yes' or 'No'.

High Blood Pressure?
YesNo

Diabetes?
YesNo

Heart Ailment?
YesNo

Thyroid Problems
YesNo

Rheumatic Fever
YesNo

Excessive Bleeding
YesNo

Asthma, Chest or Breathing Problems?
YesNO

Epilepsy?
YesNo

Tuberculosis?
YesNo

Hepatitis?
YesNo

Stomach or Bowel Problems (e.g. Ulcer)
YesNo

AIDS/HIV
YesNo

SMOKING

Do You Smoke?
YesNo

How many cigarettes do you smoke per day?

Would You Like To Stop?
YesNo

ADDITIONAL QUERIES

Would you like to discuss these questions in private with the dentist?
YesNo

Do you have: an artificial hip, heart valve or other prosthetic implant?
YesNo

Have you ever had problems with dental treatment?
YesNo

Are you presently under medical care?
YesNo

Are you taking any drugs, medicine or tablets?

Female patients, are you pregnant?
YesNo

Do you have any allergies?
YesNo

List any other previous illnesses you have.

List any medicines or products you are allergic to (i.e. Penicillin, Latex).

FORM AGREEMENT

I have completed this questionnaire to the best of my knowledge.

I understand that failure to make a full disclosure may place me at undue medical risk.

I understand that notes, radiographs (x-rays) or models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this. I also give my permission for the practice to use the above contact details to send me appointment and checkup reminders.

I agree to our privacy policy which stipulates that we only gather your information for uses within the dental clinic, and do not store information in any online databases. Read our privacy policy.