Dental Patient Form
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2NEW PATIENT FORM
At Victoria Road 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 brochure “Personal Information, Privacy and your Dentist”.
Surname:
Title:
Given Name:
Preferred Name:
Date of Birth:
Address:
Suburb:
Postcode:
Postal Address:
Suburb:
Postcode:
Home Phone:
Mobile:
Work:
Email address:
Pension Card/Health Care Card
Card No:
Expiry Date:
please circle
Vet Affairs Gold / White
Vet Affairs Card No:
Expiry Date:
please circle
Medicare Number:
Position on Card:
Name of Private Health Fund (if any)
Position No on card:
Occupation:
Employer Name:
In case of an emergency whom should we contact?
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.
SMS to Mobile
Email
Letter
Email Updates:
To be kept informed with updates on what is new in the practice, services and new dental techniques that
may affect my next visit.
No
Yes
P.T.O
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Parent category: Medical