Patient Form
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    Confidential New Patient Form

    For us to provide you with safest and best possible care, please complete the following forms. All information is kept strictly confidential.

    Personal Details:

    Title:MrMrsMissMasterMs
    First Name:
    Last Name:
    Preferred Name:
    Residential Address:
    Date Of Birth:
    Post Code:
    Home Phone:
    Mobile:
    Work Phone:
    Email:
    Occupation:
    Emergency Contact:
    Name:
    Relation:
    Phone:
    How Did You Find About This Practice?
    Google
    Our Website
    Health Fund
    Social Media
    Patient, please provide name so we can thank them
    Other, please specify
    Do you have Private Dental Insurance CoverYesNo If yes, please specify dental insurance:
    MedibankCBHSWestfundOther

    Dental History:

    Reason for your visit today:
    Last dental visit:

    How Do You Take Care Of Your Teeth?

    Manual ToothbrushElectric ToothbrushFlossInterdental Brushes e.g. PikstersSensitive ToothpasteWhitening Toothpaste

    Have You Ever Experienced Any Of The Following?

    Sensitive to hot or coldPain with chewing or bitingBleeding gums?Mouth odours or bad tasteClenching or grinding your teethMouth breathingHead/Neck AcheFood catching in between your teeth

    Would you like to discuss?

    Teeth WhiteningCosmetic Dental TreatmentsBraces/InvisalignSkin Rejuvenation
    Have you ever had Botox/Dermal Filler?YesNo If yes, when and what area did you receive it:

    Medical History:

    Yes

    No

    Yes

    No

    Yes
    No

    Medications (Prescription, Over the Counter, Herbal, Vitamins) Please List Below:

    Yes
    No

    Recent accident, Major Surgeries or Hospitalisations including hip replacements

    Yes
    No

    Allergies (e.g. Latex, Penicillin, including food allergies). If Yes, Please List Below:

    Yes
    No

    Pregnant or Breastfeeding

    Due Date:

    Yes
    No

    Have you ever been told to take antibiotics prior to dental treatment?

    Yes
    No

    Cancer, Post cancer treatments, Radiotherapy, Chemotherapy

    Yes
    No

    Heart Valve Issue

    Yes
    No

    Stents or Shunts

    Yes
    No

    Hypertension (High blood pressure)

    Yes
    No

    Pacemaker, metal implants

    Yes
    No

    Hypertension (Low blood pressure)

    Yes
    No

    Thyroid/Gland problems

    Yes
    No

    Bleeding Disorder

    Yes
    No

    Anaemia

    Yes
    No

    Diabetes Type I or II

    Yes
    No

    Haemophilia

    Yes
    No

    Asthma

    Yes
    No

    Depression

    Yes
    No

    Epilepsy

    Yes
    No

    Smoker

    CurrentPast
    Yes
    No

    Rheumatic Fever

    Yes
    No

    Drug Dependence

    Yes
    No

    Gastric Problems

    Yes
    No

    Acid reflux

    Yes
    No

    Server Headaches

    Yes
    No

    Arthritis

    Yes
    No

    Osteoporosis

    Yes
    No

    Hepatitis A, B or C

    Yes
    No

    HIV

    Yes
    No

    Thyroid Conditions

    Yes
    No

    Autoimmune Disease

    Yes
    No

    Other

    Please list any other conditions this practice should be made aware of:

    Consent for Treatment, Please read the following carefully:

    1. To the best of my knowledge all of the preceding answers in my medical and dental history are true and I have disclosed all information. If there are any changes to my health, I will inform the office at the next appointment.
    2. I do hereby authorise and request for myself or the above named patient, dental services and/or whatever procedures the doctor may deem necessary as well as the administration of local anaesthetic or pre-medications which may be deemed advisable and accept any associated risks
    3. I agree to adhere by the conditions of the practice Cancellation Policy
    4. I agree that all accounts will be settled on the day of the appointment/treatment.
    5. I agree that any photos of my teeth can be shared for educational purposes or in promotional advertisements for the practice, with my identity to remain anonymous
    Signature:
    Date:
    Please tick this box if you are signing on behalf of a minor, who you are a guardian/parent of

    Looking for ways to connect and learn more about your dental care? We are too!

    Apart from visits to our practice, we love staying in touch with our patients to share our news and views.

    PATIENT STORIES

    We Love To Help You
    Achieve That Smile You Have
    Always Dreamed Of

    Read all Reviews
    google-rating
    I found out about Timeless Smiles Dental after they won an award and were published in our local bush telegraph. The team looked friendly in their picture and were just as friendly in real life. In a convenient spot near the train line, Dr Nimesh and his team go above and beyond, they are patient, caring and thorough - just what you need 🙂
    Danielle Milliken
    I found out about Timeless Smiles Dental after they won an award and were published in our local bush telegraph. The team looked friendly in their picture and were just as friendly in real life. In a convenient spot near the train line, Dr Nimesh and his team go above and beyond, they are patient, caring and thorough - just what you need 🙂
    Danielle Milliken

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