Arena Family Dental
Mr.Mrs.Miss.Ms.Dr.Master. Your name Last name
ZIP / Postal Code Date Of Birth
Phone Mobile Phone
Your email Medical doctor name Phone
How did you find us? GoogleFacebookWord of MouthBoard at frontWalk byNIBHCFOther
Please give details if Other
Is the patient eligible for Child Dental Benefits Schedule (Medicare Scheme) ? YesNo
If yes, Medicare card no. please(Only need for kids between 2-17 years of age for CDBS under Medicare)
Medicare Card Patient's Ref no. please(Only need for kids between 2-17 years of age for CDBS under Medicare)
How would you like to pay today? EFTPOSVisaMastercardCashCDBS Medicare (only for eligible kids)
Do you have any private health insurance with dental cover? YesNo
Have you ever had any of the following: (Tick Only For Yes?) Rheumatic FeverEpilepsyKidney DiseaseHepatitis CAsthmaTuberculosisExcessive BleedingHepatitis BDiabetesHeart AilmentHigh Blood PressureHIV/AIDS
Are you allergic to any drugs, medications or latex? YesNo
If yes, please give details
Are you currently taking any medications or tablets? YesNo
Ladies: Are you pregnant? YesNo
Ladies: Are you breastfeeding? YesNo
Ladies: Are You A Smoker? YesNo
Reasons for today’s visit:ExaminationFillingScale/CleanPainSensitivityBroken ToothSwellingBleeding GumsBad BreathWisdom TeethBracesAppearance Of TeethWhiteningDenturesGrinding/Jaw Pains
How long was your last dental treatment done?
Have you ever experienced any problem with dental injections? Date
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