HORNSBY DENTURE CLINIC
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New Patient Form
Patient Information
Title
Dr
Mr
Mrs
Ms
Miss
Master
Your Name
Address
Postal Address
Date of Birth
Gender
Male
Female
Home Phone
Mobile Phone
Work Phone
Your Email
Are you a Veterans' Affairs Gold Card holder?
Are you covered by Private Health Insurance?
How did you hear about us?
Dentist
Doctor
Friend or Relative
Sign
Internet Search
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Dentist Details
Doctor Details
Referral Details
Confidential Health Questionnaire
Have you had radiation therapy to the head or neck region?
Yes
No
Do you take medication for anxiety?
Yes
No
Do you take medication for hypertension?
Yes
No
Do you take medication for osteoporosis?
Yes
No
Do you take any heart medication?
Yes
No
Do you suffer from dry mouth?
Yes
No
Do you have a transmittable disease, such as Hepatitis C?
Yes
No
Have you had any tooth extractions in the last 16 weeks?
Yes
No
Are you a smoker?
Yes
No
Do you have a latex allergy?
Yes
No
Do you have any medical conditions that may affect your treatment?
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