FormNew Patient Form Personal DetailsSelect TitleSelectMrMrsMsMissMasterDrOtherFirst NameLast NameDate of BirthEmailOccupationAddressSuburbPostcodeMobileHome PhoneWork PhoneEmergency Contact NameRelationship to youPhoneGP NameGP PhoneGP Practice AddressDo you have Dental Health Insurance?How did you find out about us?SelectFacebookGooglefriendGPPerson responsible for payment, if not yourselfNamePhoneDental HistoryAre your teeth ever sensitive to hot or cold?YesNoDo you grind or clench your teeth?YesNoDo you use dental floss?YesNoWould you like your teeth to be whiter?YesNoDo you play contact sport?YesNoIf so, do you use a mouthguard?YesNoWhen was your last visit to a dentist?How often do you renew your toothbrush?SelectAfter 1 MonthsAfter 2 MonthsAfter 3 MonthsAfter 4 MonthsAfter 5 MonthsAfter 6 MonthsAnything needs to change about your teeth?Medical HistoryPlease describe your medical history?Please list ALL your current medications, including over-the-counter and vitamins.Allergies/ Adverse Drug Reactions. I have accurately completed this medical history form to the best of my knowledge. I agree to make Identity Dentistry aware of any relevant changes to my health, including medication. I hereby give my authority for any treatment agreed upon by me, to be carried out by the dentists and their staff. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. Iunderstand that payment is due at the time of service unless other arrangements have been made. I authorise my dentist to take images of my teeth before and after my treatment. I understand these images may be used in a practice portfolio to showcase examples of dental work to other patients and my identity will remain anonymous.