Patient Intake Form

Please use this online Patient Intake Form if you want to fill out your details and NOT have it saved to our website. You will need to fill out the complete form again if any of your details change or if you haven’t had an appointment within 12 months, but you won’t have to register an account on the website and your details will not be saved online. If you want to save your answers so that you don’t need to fill out the complete form every time then please register an account, if you already have an account then please login.

Title*
Name*
Last Name*
Preferred Name
Date of Birth*
Home Address*
Please use a comma after your street name
Is your Postal Address different to your Home Address?*
Postal Address*
Please use a comma after your street name
Email*
Mobile Phone
Home Phone
Work Phone
Health Fund
Membership Number
Reference Number
Occupation*
Employer*
Referral
Whom may we thank for recommending you to our practice?
Emergency Contact
Name*
Relationship*
Contact Number*
Account Name
Relationship to patient
Account Address
Mobile Phone
Home Phone
Work Phone
Medical Questionnaire - Private and Confidential
Please answer these questions fully or discuss them with your dentist. Information about your medical history is confidential.
Past/Current Medical Conditions
Are you receiving any medical treatment at present?*
Treatment Details
Have you had any serious or long standing illness?*
Illness Details
Please indicate if you have EVER had any of the following:
Any Heart Complaint/Treatment*
Tuberculosis*
Rheumatic Fever or Heart Valve Surgery*
Any Nervous System Disorder*
High or Low Blood Pressure*
Gastric Ulcer*
Blood Disorder*
Asthama/Bronchitis/Lung Conditions*
Anti-coagulant Therapy (blood thinning)*
Radiation Therapy/Chemotherapy*
Joint Replacement Surgery*
Thyroid*
Osteoporosis or Low Bone Density*
Hepatitis, Jaundice or Liver Disease*
Epilepsy*
Treatment for any type of Cancer*
Diabetes*
Transplanted Organ or Bone Marrow*
Depression/Anxiety*
Pregnant*
Do You Smoke*
When Due?
Other Conditions
Current Medications (prescription, over the counter, herbal)*
Allergies*
Details
Medical Practitioner*
Medical Practice*
I agree that the above is a true and accurate record. I understand that Centro Dental Geraldton requires payment on the day of treatment. Any expenses, costs or disbursements incurred by Centro Dental Geraldton in recovering any outstanding monies including debt collection fees and solicitor costs shall be paid by the responsible party above. I further acknowledge that failure to attend any appointment without notice may also result in a deposit requirement prior to future appointments being scheduled. I have read and agree with the privacy statement. By signing this document you agree to this process. This form is a guide only and you should discuss any relevant matters with your dentist prior to the commencement of any dental treatments.
Date*
Agree*
By ticking this and clicking the submit button I agree to everything I've entered on this form.
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