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Bull Creek Dental

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08 9332 3608
0435 353 608

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NEW PATIENT INFORMATION FORM - CONFIDENTIAL

"*" indicates required fields

Step 1 of 4

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*

First Name*

Last Name*

Address:*

Phone*

Email*

Emergency Contact*

Contact No.*

Dental Private Health Cover*

Yes

No

Fund Name*

Membership Number*

How did you hear about us?*

Referred from family/friend

Google

Health engine

Facebook

Road Signage

Date Of Birth

Suburb

Are you receiving any medical treatment at present?

Yes

No

Name of your medical practitioner/specialist

Have you ever been hospitalised during the last 5 years?*

Yes

No

Have you ever had or are you currently receiving treatment for cancer?

List any medicines/injections you are taking (including oral contraception, HTR, naturopathic, herbal and over the counter medicines)

Yes

No

Details:

When was your last dental visit?

Rheumatic Fever

yes

Tuberculosis (TB)

Yes

Depression / Anxiety Disorder

Yes

Any Cardiac (Heart) Complaint

Yes

Epilepsy

Yes

Any Cardiac (Heart) Surgery

Yes

Nervous System disorder

Yes

A Cardiac pace Maker

Yes

Thyroid Disease (Including Goiter)

Yes

High or low blood pressure

Yes

Anti-Coagulant (Blood Thinning) Medication

Yes

Asthma

Yes

Blood Disorders

Yes

Gastric Ulcer

Yes

Do you have AIDS or HIV?

Yes

Do you smoke?

Yes

Excess brushing or bleeding

Yes

Dry Mouth

Yes

Osteoporosis or low bone density

Yes

Snoring or Sleep Apnoea

Yes

Bisphosphonate treatment

Yes

CPAP machine

Yes

Joint replacement surgery

Yes

Are you pregnant?

Yes

Diabetes Type :

Yes

Family history of Diabetes

Yes

Are you Breastfeeding?

Yes

Hepatitis Type (A,B,C,D,E) :

Yes

Allergy or reaction to any medicine (Including penicillin or other antibiotics)

Yes

Jaundice or liver disease

Yes

Allergy to any food or substance (Such as Chlorine, latex, antiseptics)

Yes

Would you like to discuss any of the following:

Replacement of missing teeth

Crowns, Veneers

Tooth grinding

Dentures

Cosmetic appearance

Tooth whitening

Clenching

Implants

Removal of wisdom teeth

Bad breath

Bleeding gums

Root canal treatment

Replacement of fillings

Full Name

Today's Date*

Contacts

If you have any questions or need help, feel free to contact us for medical assistance.

(08) 9332 3608

Unit 1/79 Wheatley Drive, Bullcreek, WA 6149

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GENERAL
DENTISTRY

GENERAL DENTISTRY

Bruxism
Checks up and clean
Clenching
Dental Fillings
Extractions
Gum Disease Treatment
Root Canal Therapy
Snoring and sleep apnoea
TMJ Treatment
X-ray’s

COSMETIC
DENTISTRY

COSMETIC DENTISTRY

Composite & Porcelain Veneers
Dental Bridge
Dental Crowns
Smile Makeovers

DENTURES

Denture repair
Full Dentures
Partial dentures

SLEEP DENTISTRY

Intravenous Sedation
Oral Sedation

EMERGENCY DENTIST

Abscess
Chipped-tooth
Lost Fillings or Crowns
Toothache

TEETH WHITENING

In-chair whitening
Take home whitening

KIDS DENTISTRY

First Dental Visit
Fissure Sealants

DENTAL IMPLANTS

All-on-4-implants
Bone Grafts
Implant Supported Dentures
Multiple Implants
Single Implants

MOUTH GUARDS

Custom made mouth guards

INVISALIGN

Invisalign®
Clear aligners

AREAS

Dentist Brentwood
Dentist Bateman
Dentist Rossmoyne
Dentist Willetton
Dentistry Leeming

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