New Patient Information Form

New Patient Information Form


You must be the Child's Legal Guardian to complete this form. Please confirm you are the Child's Legal Guardian.

Patient Details

Address *
Have you been to see us before?

Referral Details

Has a written referral been provided? *

Legal Guardians

All legal guardians must be listed on this form. Only legal guardians may request and receive information relating to the patient's dental information.
Parent Responsibility
Is there a Court Order/Pending Court Order/Formal Family Agreement?

Parent 1 / Legal Guardian

Parent 2 / Legal Guardian

Emergency Contact

Private Health Fund

Do you have Private Health Insurance *

Medicare details

Medical History

Has your child had a previous General Anaesthetic? *
Is your child taking any medications?
Does your child have any allergies, including drugs, medications and latex?
Are your child’s immunisations up to date? *
Please tick the following Medical Conditions that apply to your child *

Dental History

Is your child currently experiencing any pain? *
Did your child have an accident and injure their teeth? *


By submitting this form I acknowledge, to the best of my knowledge, all the preceding answers are true and correct. I also acknowledge that I am responsible for all fees incurred at the conclusion of each appointment *
I acknowledge this is a Specialist Private Practice and as such Specialist Fees will be charged
I acknowledge my fees will not be bulk-billed