114 Lake Road, Northcote, Auckland.
Tel: 09 480 6629 [email protected]
Please be as accurate as possible when completing this questionnaire. The information you provide is kept
Title________ First names_______________________ Surname___________________________________________

Date of birth ______/_______/___________ Occupation__________________________________________________

Postal Address________________________________________________________________ Postcode_____________

Telephone: Mobile__________________________ Work _____________________ Home_______________________

Email _________________________________________ I wish to receive emails regarding news or promotions

Name and contact of next of kin ______________________________________________________________________

Were you referred to the practice by one of our patients? (Please name) _____________________________________

How did you hear about us?__________________________________________________________________________

Name of Last Dentist_____________________________________________ Date of last visit_____________________

Name of Medical Practitioner_______________________________________Location___________________________

Are you in any pain presently? Y/N Do you need to take antibiotics prior to dental treatment? Y/N

Please list the medications you are currently taking.______________________________________________________

Is there anything about your teeth you would like to discuss with the dentist?______________________________

Do you have any allergies to medicines, anaesthetics, latex, penicillin? Please list _____________________________

Are you a smoker? Y/N Are you pregnant? Y/N If so, how many months?______________________

Please tick if you have had any of the following:

Anaemia Depressive Illness Heart Murmur Nervous problems

Rheumatic Fever

Arthritis Diabetes Hepatitis A,B,C Osteoporosis Severe headaches

Asthma Epilepsy/Seizure Pacemaker Stroke High Blood Pressure

Cancer Excessive Bleeding Tuberculosis Prosthetic Joint Low Blood Pressure
IV/Aids C
hest Problems Gast
ric issues
Hearing/Sight issues
art conditions Liv
er/Kidney problems Reac
tion to Anaesthetic

CONSENT FOR TREATMENT: I authorise the dentist/designated staff to perform all recommended treatment deemed

appropriate by the dentist to make a thorough diagnosis. I agree to be responsible for payment of all services
rendered. I understand payment is due at time of service. Cost incurred in relation to collection of overdue accounts
will be charged to the account holder. By signing below I understand and accept these terms and conditions.

Signed by Patient/Parent/Guardian________________________________________Date ____/______/__________


Source: http://www.114dental.co.nz/114/media/New%20Patient%20Form.pdf


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