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

First name

Last name

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Email

Emergency Contact Name:

Emergency Contact Number

Are you in a health fund?

Yes

No

Name of fund

Medicare card number

Position on card:

How did you hear about us?

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

Do you have any current or past dental issues? (e.g., tooth pain, sensitivity, gum disease)

Are you currently experiencing any dental pain or discomfort?

If yes please describe

Have you had any adverse reactions to dental treatments in the past? (e.g., reactions to anesthesia, excessive bleeding)

Medical Screening

List all medications you are currently taking

Have you been hospitalised in the last 2 years? If so please provide details:

Do you smoke?

Name of Doctor (GP)

Location

Name of Doctor (Specialist 1)

Location

Name of Doctor (Specialist 2)

Location

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

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.

Signature

Signature field is empty.

Name

Relationship to Patient:

Date

Month

Day

Year