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Add: 24c Macquarie St Belmont, NSW 2280 | P: (02) 4945 8999 | F: (02) 4945 8972 | E: click here
Add: 2nd Flr, 161 Maitland Rd Mayfield, NSW 2304 | P: (02) 4968 2303 | F: (02) 4967 2171 | E: click here

Your Medical and Dental History

As a new patient we need to get to know you and your medical and dental history so that we can gain a comprehensive understanding of your current and past oral health to provide you with the highest quality treatment. For this reason we will request that you complete a New Patient Form. This can be done in just a few minutes at our practice, prior to your appointment.

However, for your convenience, we have also made this form available online, so the answers will be sent straight to our practice. Alternatively, you can also download to form to complete at a time that suits you. Then, simply fax the completed form back to us or bring it to your appointment.

Download from here.

Please fax any completed forms to Belmont (02) 494 589 927.

Mayfield (02) 4968 2303

Patient Information
Title:    
Surname:* Given Name:*
Preferred Name: Date of Birth:*
Address:* Suburb:*
Postcode:*    
Ph (home):* Mobile number:
Ph (work):  
E-mail:*
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.
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.
How did you hear about us?
Referral Source:    
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)


























Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify)

What medications including natural remedies are you taking?
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.

 

Dentistry

Patient Referral Program


It gives us great pleasure knowing so many of our patients have recommended our high quality service to family, friends and colleagues. We appreciate this compliment and have sent out many rewards to our patients to say thank you for the referrals.

New Patient Offer


Comprehensive Dental Assessment (Valued at $373) Includes:

  • Comprehensive Examination
  • Professional Clean and Polish
  • Diagnostic X-rays if required
  • Fluoride Treatment
  • Digital imaging tour of your mouth

Corporate Dental Program


Newcastle Family Dental along with DENTAL CARE NETWORK ™ is offering the Corporate Dental Program which provides you with exclusive benefit of a complimentary $100 service voucher to be redeemed for dental treatment if you are an employee of one of our partnered corporate programs.