New Patient Registration Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Date of birth MM DD YYYY Occupation Referred By Doctor's Name Emergency Contact First Name Last Name Contact Phone (###) ### #### Dental History Previous/Current Dentist's Name Is this ACC related? Yes No If relating to an existing ACC claim, please provide claim number Are you having pain or discomfort at this time? Yes No Do you feel very nervous about dental treatment? Yes No Are you happy with the appearance of your teeth? Yes No Reason for attending appointment Medical History Have you been hospitalized in the last two years? Yes No Are you being treated for any health related condition now? Yes No If you answered yes above, please advise on your condition(s). Are you currently taking any medication? Yes No If you answered yes above, please advise on your medication(s). Are you allergic to, or made sick by (ie itching, swelling of hands, feet or eyes) penicillin, aspirin, codeine or any drugs or medication? Yes No If you answered yes above, please advise what you are allergic to. Have you ever had excessive bleeding? Yes No Tick any of the following which you have had or have at present Artificial Joint Asthma Diabetes Fits or Epilepsy Heart Trouble Hepatitis or Jaundice High Blood Pressure Osteoporosis Rheumatic Fever HIV or AIDS Cold sores Do you have any disease, condition or problem not listed? Yes No Are you currently pregnant? Yes No At time of appointment, will you be paying by Cash EFTPOS Credit Card * To the best of my knowledge, all of the preceding answers are true and correct. Thank you for your registration! Our friendly team will be in touch soon to schedule an appointment with you.Have a great day!
