Online Patient Form 

We have a general new patient form which we can input and then make changes to this as you see fit.

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. Click here for our privacy policy.

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.
Captcha
Please enter code from image

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.

 

Email us click here


Opening Hours

Monday: 9:00am until late
Tuesday: 9:00am until 5:00pm
Wednesday: 9:00am until late
Thursday: 9:00am until late
Friday: 9:00 am until 4:30pm
Saturday: By appointment
Same day emergencies by appointment


Our Location

Camden | Maps
61 Argyle Street
Camden NSW 2570

Bupa Dental Narellan | Maps
Suite 15, 1 Elyard Street
Narellan NSW 2567


Parking

Camden Click here
Bupa Dental Narellan Click here