Form New Patient Form Personal Details Select TitleSelectMrMrsMsMissMasterDrOther First Name Last Name Date of Birth Email Occupation Address Suburb Postcode Mobile Home Phone Work Phone Emergency Contact Name Relationship to you Phone GP Name GP Phone GP Practice Address Do you have Dental Health Insurance? How did you find out about us?SelectFacebookGooglefriendGP Person responsible for payment, if not yourself Name Phone Dental History Are your teeth ever sensitive to hot or cold?YesNo Do you grind or clench your teeth?YesNo Do you use dental floss?YesNo Would you like your teeth to be whiter?YesNo Do you play contact sport?YesNo If so, do you use a mouthguard?YesNo When 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 Months Anything needs to change about your teeth? Medical History Please 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.