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 09 235 7597

Patient Information
Title:
Surname:* Given Name:*
Preferred Name: Date of Birth:*
Address:* Suburb:*
Postcode:*
Ph (home):* Mobile Number:
Ph (work):
E-mail:*
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.
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?:
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.

 

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Surgery Opening Hours

Click here to view our opening hours.

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Our Location

Unit 2, 26-30 Constable Road,
Waiuku, Auckland 2123, New Zealand

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Parking

Parking available.
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Our Services

We pride ourselves on being a 'One Stop Shop' for all your dental needs and offer a wide range of services that we will tailor to suit your individual needs and requirements. 

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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.

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Frequently Asked Questions

Got a question? With a desire to keep you informed we have included some of the most common questions that we get asked here at The Dental Practce. Check to see if your questions is there and if not, feel free to email us an inquiry or contact our friendly team for more information. 

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Online Patient Form

To complete or download our medical and dental history form before your first appointment.

Go to patient form