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New Patient Form


Watagan Dental New Patient Form

Please complete this form to help us provide the best care for you. If the patient is unable to complete this form, a next of kin or legal guardian may fill it out on their behalf.


Patient Information

Birthday
Month
Day
Year
Multi-line address
Are you in a health fund?
Yes
No

Dental History

Have you visited a dentist before?
Yes
No
How long since your last dental appointment?
less than 6 months
6 to 12 months
1 to 2 years
longer than 2 years
Are you currently experiencing any dental pain or discomfort?

Medical Screening

Are you allergic to any of the following?
Do you have any of the following medical conditions?

Patient Photography Consent

In certain circumstances, photography may be taken as part of your consultation to monitor and assist in managing conditions. These images will form part of your medical record.

I consent to photographs being taken, stored in my dental record.
Yes
No
I consent to my photographs being de-identified and used for medical education, teaching, or research purposes, including publication in medical journals.
Yes
No
I consent to my de-identified photographs being used for website or publicity purposes.
Yes
No

Consent For The Use Of An Electronic Scribe

At Watagan Dental, we strive to provide you with exceptional care and focus during your visits. To enhance the quality of our consultations, we use a secure note-taking tool to accurately document our discussions and the outcomes of your appointments for our dental record. No recordings are kept of these conversations.

I consent to the use of an electronic scribe to be used during my appointment.
Yes
No

Cancellation Policy

To ensure all patients have an opportunity to get the treatment they need we require 24 hours notice of appointment cancellation. Canceling with less notice than this will incur a fee. Please see our cancellation policy at: https://www.watagandental.com.au/services/cancellation-policy

Signature

I confirm that the information provided is accurate to the best of my knowledge. If completed by a next of kin or legal guardian, I confirm my authority to provide this information on behalf of the patient.

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Date
Month
Day
Year

SEE YOU SOON

We're conveniently located on Freemans Drive in Cooranbong. You will find plenty of free parking at the rear of the building right next to our comfortable and relaxing reception. 

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646 Freemans Drive, Cooranbong NSW 2265

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Monday - Friday:

9am - 5pm

Book Your Visit Online

View available appointments and enjoy dentistry done right. Don't forget to let us know if you want white teeth for life!

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