New Patients

Tell us all about you

New patient form

You don’t need a doctor’s referral (except for DVA).  Please use the below form to tell us all about you so we can make everything comfortable for you.

New Patient Form

Patient details

Address
Address
City
State
Postcode
Is the patient the person completing this form?

Your details

Address
Address
City
State
Postcode
Is the Emergency Contact / Person responsible, same as above?

Emergency Contact / Person Responsible

Address
Address
City
State
Postcode

Medical details & history

Do you have Health Insurance?
iCare Participant?
Do you require an iCare report?

Maximum file size: 16.78MB

Do you have a disability?
Do you have a mental illness?
Do you have a history of causing behavioural harm?

Maximum file size: 16.78MB

Do you have an Oral Care Plan?
Do you have any other Plans?
(e.g. diet, dysphagia, behaviour, epilepsy, NDIS)

General Medical Practitioner Details

Practice address
Practice address
City
State
Postcode

Dental Details

Dentist's address
Dentist's address
City
State
Postcode
When was your last dental visit?
How often do you usually visit the dentist?
Do you have a history of trauma to the head/neck/teeth?
Do you have jaw joint pain, clicking or locking?
Brushing teeth
How many times per day do you brush?
Do you brush teeth Morning AND Night?
If the dentist is running late, is this going to be an issue?
Do you have any sensory issues?
I can transfer to the dental chair
Do any of the following affect your ability to comply for dental treatment?
Have you had sedation for dental treatment previously?
Would you like us to email images for a social story before the appointment?
Do you have difficulty cooperating due to cognitive impairment or dental phobia?