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About Us
- Meet Our Team
- Careers
Services
Patient Information
- Cancellation Policy
Blog
Book Online
- CALL (02) 9419 5506

New Patient Medical History

Name: Dental Services
Brand: Simply Dental Chatswood
Rating: 5 (275 reviews)

Step 1 of 4

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Please take your time to complete this form in as much detail as possible. All information is kept STRICTLY confidential. We do not share any of your records with anyone unless you authorise us to do so.

Your Details

Name*

Title Given Names Surname

Email*

Mobile*

Date Of Birth*

Day

Month

Year

Gender

Occupation

Home Phone

Including Area Code

Work Phone

Including Area Code

Residential Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Postal Address

Same as residential adress

Postal Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Do you have private health insurance with dental extras cover?*

Yes

No

Private Health Fund Name*

Preferred Contact Method*

SMS

Email

Phone

How did you hear about us?*

Google/Website

Walked Past/Business Signs

Family or Friend

Word of Mouth

Facebook or Instagram

Other

Referee Name*

Name of the referee so that we can thank them.

Appointment Booking Experience

On a scale of 1 to 5, where 1 is the least satisfied and 5 is the most satisfied, how was your overall experience when booking the appointment?

1

2

3

4

5

What could we have done better to improve your appointment booking experience?*

Your Emergency Contact Details

Contact Name*

First Last

Contact Phone*

Dental History

Your Last Dental Exam*

When was your last dental examination and clean? If unsure, provide an approximate month and year.

Are you experiencing pain, discomfort or any other problem related to your dental and oral health?*

Yes

No

If yes, please provide details.

Details

Would you like the oral health professional to assess your teeth shade and advise if you are a suitable candidate for professional teeth whitening?*

Yes

No

Do you suffer from or have sometimes noticed any of the following symptoms?*

headache, jaw joint and/or ear pain

aching teeth, particularly just after waking up

aching and/or stiffness of the face and temples just after waking up

aching or stiffness in the jaws while chewing, particularly during breakfast

clenching the jaw when angry, anxious or concentrating

Unsure

None of the above

Do you suffer from anxiety from visiting a dentist or have you ever had a bad experience at a dentist?*

Yes

No

If yes, please provide details.

Details

Are you happy with the overall appearance of your teeth and smile?*

Yes

No

If no, please provide details.

Details

Purpose of Your Visit*

What is the main purpose of your visit to us?

Please select one or more of the following services that you would like to discuss with your clinician.*

Sports Mouthguard

Teeth Straightening or Invisalign

Crowns (Caps)

Replacing Missing Teeth

Replacement of Amalgam (Silver) Fillings

Other

None

Your Medical History

GP Name*

GP Contact Details*

Name, address and phone number.

Medical Conditions*

Please select all the medical conditions that are applicable to you. Select "Other" if the condition(s) is not listed. Select "None of the above" if you have no medical conditions to report.

High Blood Pressure

Low Blood Pressure

Diabetes (circle Type I or II)

Asthma/Breathing Problem

Stomach/Bowel Problems (eg Ulcer)

Tuberculosis

Kidney Disease

Thyroid or Endocrine

Excessive Bleeding or Blood Disorder

Epilepsy or Seizures

Hepatitis

AIDS/HIV

Cancer or Tumor

Radiation Treatment

Bone Disorders or Disease

Chemotherapy

Rheumatoid or Arthritic Condition

Acid Reflux

Anaemia or Fainting

Creutzfeldt-Jacob Disease

Special Care or Learning Disability

Mental Condition

Pregnant

Anticipating Pregnancy

Smoker

Other

None of the above

Medical Condition Details*

Please list details for the conditions selected above.

Allergies*

Please list any allergies, including medicines and products (e.g. Penicillin, Latex). If none, please write "None".

Medications*

Please list all medications that you are taking. If none, please write "None".

Consent & Acknowledgement

I have completed this Questionnaire to the best of my knowledge, and understand that failure to make a full disclosure may place me at undue medical risk. I also give my permission for the practice to use the above contact details to send me an appointment and check-up reminders.

Consent*

I agree.

Cancellation Policy

I have read and understood that a cancellation fee may be charged for short-notice cancellations or missed appointments. Click here to read our Cancellation Policy .

Consent*

I agree to the Cancellation Policy.