New Patient Form

At St Albans Dental Centre 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”.

Download PDF version from here.

Personal Details
Surname: First Name:* Title:
Address:* Suburb:* Postcode:*
Home Phone:* Mobile Phont:
Business Phone: E-mail:*
Date of Birth: Occupation:

Preferred Method of contact:
Are you happy with the appearance of your teeth?
Medical History
Doctor's Name:
How long is it since your last thorough dental examination:
Are you currently being treated for any health related issues?
Have you been admitted to hospital in the last two years?

Do you have or have you had any heart problems?
Other:

Have you, or any member of your family, ever had excessive bleeding or bruising?

Do you smoke?
If yes, how many a day?:
Please tick if you have or have previously had any of the following:
Other:
Medical History Questions

Are you taking any tablets, medicines, inhalers or injections of any kind?
If yes, please specify:

Have you previously had an allergic reaction? e.g to pills, medicines (such as penicillin), latex or local anaesthetic
If yes, please list:
Are you pregnant? Due Date:
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:
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.
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.

 

 

  • Appointment not attended or cancelled without 24 hours notice will be charged for.
  • Payment is required on the day of treatment. If an account is taken away, an administration of 10% will be added.
  • Any unpaid debt will be forwarded to a collection company, expenses incurred in this process will be charged to the patient.
  • St Albans Dental Centre reserves the right to discontinue treatment on a patient at our discretion, for any reason.
  • St Albans Dental Centre reserves the right to take a sample of blood for analysis in the case of a needle stick injury to a staff member.

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Surgery Opening Hours

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Our Location

144 Cranford St St Albans, Christchurch 8014, New Zealand

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Parking

Parking available.

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