New Patient Form - Towngate Dentall

New Patient Form

The information that is requested on this Questionnaire, Dental History and Medical History is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly.
Please include city and post code.
Please provide all numbers that are available - Home, Work, Cell. As well as Spouse Cell + Work.
I consent to be contacted by Email if I have provided my Email address to the office.

MEDICAL INFORMATION:

HEALTH HISTORY:

(Please answer yes or no. If unsure of a question, please consult with the dentist.)
If so please list.
If yes, please list:
If yes, please list:
If yes, please list:
If yes, please list:

Women Only:

Dental History

(Please answer yes or no, where applicable. If unsure, please consult with the dentist).
If yes, does it affect your sleep?
(surgery in or about the mouth/jaw joint, or implant surgery in one or both of your jaws)
and, what would you like to see changed?