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Online Patient Form

We strive to provide you with
the highest possible care.

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Online Patient Form

At Face Value Dental we strive to provide you with the highest possible care. To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present. Without this information it is difficult for your dentist or hygienist to plan your care properly.

Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation. If you would like any further information about how we use and protect your personal information, please ask one of our staff for our “Personal Information, Privacy and your Dentist” document. Click here for our privacy policy.

Patient Information
Title:
Surname:* Given Name:*
Preferred Name: Date of Birth:*
Address:* Suburb:*
Postcode:*
Ph (home):* Mobile Number:
Ph (work):
E-mail:*
Vet Affairs Vet Affairs Card No:
VA Expiry Date:
Name of Private Health Fund (if any): Position No on Card:
Occupation: Employer Name:
Next of Kin
Name: Relationship: Phone:

In case of an emergency whom should we contact?

Please indicate if different to next of kin.

Name: Relationship: Phone:
Reminder System

We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.

Dental History
How long is it since your last thorough dental examination?:
Please tick any dental concerns you have?
Medical History
How do you rate your general health?
Who is your General Practitioner?:
Telephone:

Have you had or are you suffering from any of these? (please tick)

Please list the medications you are taking:
Please list any allergies to drugs, foods or materials:
Is there anything else the Dentist or Hygienist should be aware of?:
Are you with a Private Health Fund? If so, which one?:
How did you hear about us?
Referral Source:    
Keep Informed Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
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Consent for Services

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.

 

Please visit this page on desktop to fill up the form.

Members First Provider for:

  • BUPA Members First Provider
  • HCF

Face Value Dental is now QIP accredited. For more information about what this means for you, click here.