A1 Dental Care

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Barton

8A/3 Sydney Avenue, Barton

Call A1 Dentistry in Barton 02 6273 8885

Belconnen

5F/21 Benjamin Way, Belconnen

Call A1 Dentistry in Belconnen 02 6251 9991

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New Patient Barton

Fields marked with * are required

Please fill out your personal details and answer the following questions below to register as a new patient at A1 Dental Care.

You will be required to sign a hard copy of your registration form when you attend our clinic in person.

Previous Dentist's Details

In order to give you the best service we would like to know the information of your previous dentist so that we can request your dental history & records from them.

Dental Practice:

Dentist Name:

Contact Telephone Number:

Personal Details

Title *

Surname *

First Name *

Email *

Phone Number *

Additional Contact Number (i.e. work or home)

Date Of Birth *

Occupation *

How did you discover our surgery? *

Purpose of Visit *

Private Health Fund *

Health Fund Number *

Person Number: *

Name of person responsible for fees if not self

Is another member of your family a patient of our practice? *

Yes

No

Address

Street *

Suburb *

State or Territory *

Postcode *

Have you ever had any of the following?

Heart Problems *

Yes No

Blood Pressure *

Yes No

Artificial Joints *

Yes No

Circulatory Problems *

Yes No

Rheumatic Fever *

Yes No

Radiation Treatment *

Yes No

Excessive Bleeding *

Yes No

Excessive Bruising *

Yes No

Sinus Trouble *

Yes No

Liver/Kidney Problems *

Yes No

Epilepsy *

Yes No

Allergies to Anaesthetics *

Yes No

Allergies to Penicillin *

Yes No

Allergies to Dairy *

Yes No

Allergies to Medications *

Yes No

Allergies to Latex *

Yes No

Diabetes *

Yes No

Asthma *

Yes No

Hepatitis A/B/C/D/E *

Yes No

Tumour History *

Yes No

Osteoporosis *

Yes No

HIV *

Yes No

Are you currently taking any medications? *

Yes No

If 'Yes' please list

Have you had any of the following:

Does your jaw click or hurt? *

Yes No

Do you feel you grind your teeth? *

Yes No

Have you ever had orthodontic treatment? *

Yes No

Do you wear a night guard? *

Yes No

Have you ever had gum disease? *

Yes No

Have you ever had your bite adjusted? *

Yes No

Do you bite your lips or cheek often? *

Yes No

Do you smoke? *

Yes No

Do you think you have occasional bad breath? *

Yes No

Do your gums ever bleed when you brush your teeth? *

Yes No

Do you experience sensitivity with hot/cold? *

Yes No

Does floss ever tear between your teeth? *

Yes No

Does food get jammed between your teeth? *

Yes No

Do your teeth ever hurt when you bite hard? *

Yes No

Name or your physician? *

Physician's practice address *

Physician's phone number *

Are you pregnant *

Yes No

If yes, what is the due date? *

How long has it been since your last dental appointment? *

How often do you have dental examinations? *

Previous dental x-rays were taken: *

Less than one year ago Longer than one year ago

Do you have any affiliation with an embassy or commission? *

Yes No

If so, whom? *

Cancellations

We understand that circumstances do arise where it is unavoidable to cancel at short notice. However, we do prefer where possible, to have 24 hours’ notice if you are cancelling your appointment so that we are able to give this appointment to another patient in need of attention.

We do have a priority list for our patients waiting for an available appointment at short notice. With the appropriate notification, we are then able to assist these patients, who may have emergencies and be in pain. As we’re a busy practice it’s likely you may be offered or need to use this at some stage. We appreciate your courtesy.

I have read, understand and agree to this cancellation policy and the terms and conditions. Please contact our clinic on the number outlined below if you have any questions or any concerns regarding opening or viewing any attachments, and a member of our friendly team will gladly assist you.

Quick Enquiry

Fields marked with * are required

Name *

Phone *

Email *

Message *

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