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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
    Nimesh did a wonderful job! I went to Timeless Smiles to straighten my teeth using Invisalign. You will be seeing your dentist every 2nd month, so make sure you have a good one! Not only did we fix my teeth, but we were able to laugh along the way. Highly recommend for Invisalign, TMJ issues or just a checkup, they do it all there!
    Danielle B
    We have been seeing Dr Nimesh Practice for 7 years now. We took our toddler for his first visit last week and the experience was so beautiful. He was explained each step and our toddler is already looking forward to his next visit 😁
    Renee Vassallo La Rosa
    The best dentist I’ve been to. Dr Patel offered an in depth consultation, a friendly, non-judgemental environment and I felt very comfortable in his and his staff’s hands. They worked to offer the best price and the whole process was very easy. Thanks so much!
    Sophie Bryce
    Absolutely delightful experience. Dr Patel and his friendly staff make you feel welcome and taken care of from the second you walk into the beautiful office. Cannot recommend this practice more highly!
    Emma Timmins
    The best dental practice I have ever been do, my lovely dentist, Dr. Aditi Khamar treated me so well. Always answered my questions and was so bubbly and polite.
    Better Self Counselling
    My family and I have been seeing Dr Patel for over 7 years. Dr Patel and his team are always accomodating, very professional and make going to the dentist a seamless and pain free experience. I would not hesitate to recommend him to friends or family.
    Anmol. P
    Great experience at Timeless Smiles, for the whole family. Thank you for looking after us! Would recommend to anyone. Personally I had 4 fillings, easy, pain free and look great, you wouldn't know they were there.
    Tahlia McRae
    Dr Nimesh has been great, my invisalign treatment was impeccable and I'm very happy with my teeth now.
    Pierre Vassallo La Rosa
    Dr Nimesh and Dr Aditi are both professional and kindness, very gentle and caring. Thank you so much 🌷
    Ita Wei
    Dr Names was great throughout my Invisalign treatment. He explained everything thoroughly and I'm really happy with the results.
    Stephanie Schwecke
    Dr Nimesh is the best in area.I had my treatment done with him and I was explained everything in detailed.Good service.Highly recommended.
    Urvi Patel
    Dr Nimesh and the staff at Timeless are always helpful and provide the best dental care. They have been a great help during dental emergencies.
    Alan Teuku
    Dr Patel has great chair-side manners. I am impressed with his patience during detailed discussion about the dental care I needed. Thank you Dr Patel.
    Vaidehi Desai
    Great family friendly dental clinic. Dr Patel has done great job with our family’s teeth, including braces and Invisalign for different family members.
    Ken Johnstone
    I had filling in one of my back tooth without injection. Dr Nimesh Patel is very gentle and his staff is very helpful. They made my visit very comfortable.
    Keta Adhvaryu
    The best dental practice I have ever been do, my lovely dentist, Dr. Aditi Khamar treated me so well. Always answered my questions and was so bubbly and polite.
    Better Self Counselling
    Our family dentist for more than 7 years. Dr Patel is very supportive, guides you and informs you about the processes and the needs for it. No pressure and non judgmental attitude.
    Rich Joshi (Vego Wanderer)
    Dr Nimesh Patel and his team are excellent! They did an amazing job with whiting and looking after my teeth! If your looking for a great dentist I highly recommend Timeless smiles!!
    Tanaya Thomson
    Really happy with my experience. Dr Patel and his team are so welcoming kind and professional. I always have a pleasant experience with them all ! Thanks guys for making it so good !
    Sally Jammal
    Been going to nimesh for a few years now. Got my Invisalign done with him and had a filling done on a back tooth without a needle & pain free. Very kind and friendly staff always making me laugh!
    Jess Parker
    Absolutely delightful experience. Dr Patel and his friendly staff make you feel welcome and taken care of from the second you walk into the beautiful office. Cannot recommend this practice more highly!
    Emma Timmins
    Thank you Dr Nimesh for helping with my Dental implant crown. I had my implant done overseas and crown came off very soon. Dr Nimesh helped me to sort this out within few days to avoid infection in my gum.
    Tejashree Gorakhia
    Fantastic staff and the dentist was excellent. They are more than willing to help out the local community, and gave me a great deal as a student. The dentist worked carefully around sensitive areas, I'll be back for sure
    Nicholas Fitzgerald
    Dr Nimesh and staff were professional from the get go. They have taken the time and patience to keep me informed of what happens in an appointment. This put me at ease and the appointment went well. Keep up the good work.
    Venu
    Great practice, I come here regularly and always have a good experience, feeling taken care of as soon as I walk in the door. The staff are super friendly and Dr Nimesh always listens to me and has my best interests at heart.
    Peita Jones
    Very professional business. They explained their process very clearly and were happy to answer any questions I had and made new recommendations along the way. Wouldn’t hesitate to recommend any family or friends looking for great service.
    John Grima
    Dr Patel and all staff at Timeless Smiles Dental have a very calming influence and explain all procedures thoroughly before proceeding. I have always had confidence with Dr Patel treating all my family with numerous dental procedures.
    Dianne Frahn
    Very happy with my experience at Timeless dental. They were able to explain and show me all my dental issues and worked with me to rectify them. Great service and very well priced. I will be sending the rest of my family there from now on.
    Paul Parker
    Had to find new dentist after 20 years , went to timeless smiles for a check up and 6 months later they are fantastic, quality service , highly experienced and latest technology, staff all very helpful. Would recommend to family and friends.
    Jonathan Booth
    I had my invisalign treatment done here and the Team at Timeless Smiles were so amazing. They alked me through each step and i couldn't be happier with the results. I even got some free teeth whitening kits. I can't thank Nimesh and the team enough 🙂
    Leigh Marshall
    The most friendly and comfortable Dental Surgery you could possibly find, from the moment I walked in with extreme pain from a broken tooth I was greeted with a warm friendly smile and compassion. Dr Patel is the most gentle and compassionate Dentist and should be very proud of the business he has built.
    Simon Doyle
    I am a regular patient of Dr. Patel and I can tell you that he always looks after the interests of his patients. A very ethical and professional Dentist who will listen to your concerns and offer the best treatment possible. His staff members are friendly, welcoming and accommodating. I highly recommend him.
    Albert **
    Came to this clinic two times and both the hygienist and dentist had a look at my teeth. Special thanks to Nour the hygienist, she took the time to explain the procedures to me and had a light touch the entire time. I always find going to the dentist hard, but she made sure I was feeling comfortable and well attended to!
    Sara Serenity
    I’ve been a patient of Timeless Smiles since 2014. Dr Nimesh Patel is a great dentist, highly capable, caring and understanding of my needs. I had adhesive restoration work carried out recently from earlier work done a long time ago by Dr Nimesh and I am again very happy with the results. Highly recommended for your dental needs.
    Mark Sedgwick

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