New Patient Form Book Appointment

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We provide expert service, quality and skill to give you the perfect smile.

New Patient Form

Prior to attending your first appointment, you can save time and complete the patient form online below. Alternatively, you can print out the form here.

Step 1 of 3

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Personal History
Name
Prefix First Last
Date of Birth
Home Phone
Mobile
Next of Kin: Contact Name
Next of Kin: Contact Phone Number
Your Address
Street Address City State / Province / Region ZIP / Postal Code
Email
Occupation
Do you smoke?
- Yes
- No
Would you like any help to quit smoking?
- Yes
- No
Doctors Name & Clinic
Dentists Name & Clinic
Do you belong to a private health fund?
- Yes
- No
Fund Name
Where did you hear about us?
- Local Paper
- Internet
- Friend
- Yellow Pages
- Dentist Referral
- Advertising in Mailbox

Medical History
We ask these questions for YOUR health and safety and the health and safety of our staff and patients.

Let me assure you that answering yes to any of the questions Will NOT result in prejudice or preclude you from any form of treatment.

Have you ever suffered/suffer from:
- Epilepsy, Fits or Seizures
  - Yes
  - No
- Rheumatic Fever
  - Yes
  - No
- High Blood Pressure
  - Yes
  - No
- Heart Conditions (please list below)
  - Yes
  - No
- Blood Disease
  - Yes
  - No
- Tuberculosis
  - Yes
  - No
- Anxiety
  - Yes
  - No
- Depression
  - Yes
  - No
- Stomach Issues
  - Yes
  - No
- Allergies (please list below)
  - Yes
  - No
- Diabetes (please list type below)
  - Yes
  - No
- Asthma
  - Yes
  - No
- Prolonged Bleeding
  - Yes
  - No
- HIV/AIDS
  - HIV
  - AIDS
  - Neither
- Hepatitis
  - Hep A
  - Hep B
  - Hep C
  - None
- Thyroid Problems
  - Yes
  - No
- Cancer (please describe below)
  - Yes
  - No
- Kidney Disease
  - Yes
  - No
- Bowel Issues
  - Yes
  - No
- Any other contagious disease? (please list below)
  - Yes
  - No
- Heart Valve, Hip or Prosthetic Implants?
  - Yes
  - No
Are there any other medical details about yourself, that we should know about?
Please include additional details to any questions you answered "yes" to in the above list.
Please list any medications in the space below, that you are currently taking and daily dosage.
If unsure now, please bring list to next appointment.

Denture History
Reason for your visit
How old are existing dentures
How many sets of dentures have you had
What improvements are you hoping for
Privacy Consent*
I have read the information below and understand the reasons why this information must be collected. I am also aware that this Denture Studio has a privacy policy on handling personal patient information.
We require your consent to collect personal information about you.

Please read this information and sign where indicated below.

We collect information from you for the primary purpose of providing quality dental health care.

We require you to provide us with personal details and full medical history so we may properly assess, diagnose, treat and be proactive in your dental health care needs.

This means we will use the information in the following ways:
- Administrative purposes in running this Denture Studio, including billing.
- Health Fund/Health Insurance Commission requirements.
- Disclosure to others involved in your dental health care, including treating doctors, dentists or other dental specialists outside this denture centre practice. This may occur through referral to a doctor, dentist or dental specialist.
I understand that if my information is to be used for any other purposes other than set out above, my further consent must be obtained.

I consent to the handling of my information by Diamond Denture Studio for the purpose set out above, subject to any limitations on access or disclosure that I notify this Denture Studio of.
Patient Signature

Diamond Denture Studio
190 High Street
Hastings VIC 3915
(03) 5979 3007