new patient form

We designed this online new patient form for anyone who dislikes filling forms at a dental surgery when going for an initial visit. Once the form is received, we'll transfer the information to our normal paper form, and have it ready for your signature when you arrive. We recommend that you read our patient information prior to completing the form.

This form is intended as a convenience for our on-line new patients. There is no requirement to submit this form. You can simply fill out the form during your first visit if you prefer or you can download it here and complete it prior to your visit.

personal details

Name:

Preferred form of address:

Address:

Date Of Birth [DD/MM/YYYY]:		Marital Status:
Mobile Phone no:		Home Phone no:
Work Phone no:		E-mail address:

We confirm your appointments. How do you prefer us to contact you?

Mobile

Work No.

Home No.

Text

Occupation:

What is your PPS (PRSI) No?:

Who would we contact in an emergency? (name & telephone no.):

Who is your family doctor? (name, phone number & location):

We hope that you will be very satisfied with the care you receive here. We would like to know what made you choose us:

	Convenient location		Referred by another dentist
	Recommended by friend		Yellow Pages
	Convenient surgery times		Internet
	Family member already attending here		Any other reason
	Emergency treatment

If ‘any other reason’ please state:

If you have left another practice to come here and you think it is important to tell us why, please do so:

confidential medical history

The following information is required to enable us to provide you with the best possible care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

	YES	NO	FURTHER DETAILS
ARE YOU
Attending or receiving treatment from a doctor, hospital, clinic or a specialist?
Taking ANY pills, tablets or medicines, including oral contraceptives or bisphosphonate medication?
Pregnant or nursing? If pregnant what is the expected date of birth?
Allergic to any medicines, latex or anything else (e.g. hay fever)
Taking or have taken steroids in the past year?
HAVE YOU
Had any serious illness/operation in the past?
Had Rheumatic fever or infective endocarditis?
Had jaundice, liver, kidney disease or hepatitis A, B, C, D or E?
Had heart trouble, angina, high blood pressure?
DO YOU/ DOES YOUR
Suffer from fainting spells, blackouts or epilepsy?
Have abnormal blood pressure, high or low?
Suffer from diabetes?
Have any lung problems, breathing difficulties or asthma?
Bruise easily or suffer from excessive bleeding after a cut?
Have any stomach trouble?
Have any medical prosthesis, hip replacement, artificial heart valve, pacemaker?
Smoke?
Drink alcohol?

dental history

Do you have any active dental problems at the moment?

Date of last dental visit

Last dental cleaning

Last x-rays

What was done at your last dental visit?

How often do you have dental examinations?

How often do you brush your teeth?

How often do you floss?

What other cleaning aids do you use?

Are any of your teeth sensitive to:

Have you ever had:

a) Hot or cold?		Dental implants?
b) Sweets?		Braces?
c) Biting or chewing?		Root fillings?
		Periodontal/gum treatment?
		Oral Surgery?
		A bite plate or mouthguard?
		Crowns/bridges?
About your gums:		Any teeth been ground or bite adjusted?
Do your gums bleed or hurt?
Have you noticed loose teeth?		Have you experienced:
Does food get caught between your teeth?		Clicking of the jaw joints?
		Pain of jaw joint?
Do you:		Difficulty in opening or closing the mouth?
Clench/grind your teeth awake or asleep?		Headaches/ neck aches or shoulder aches?
Hold foreign objects between your teeth habitually (e.g. nails, pencils, pens)?

Are you satisfied with the appearance and colour of your teeth?

If not, what is your biggest concern?

Are you nervous of dental treatment?

If yes, what are your concerns?
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