To make your visit more smooth and efficient, please fill the below online form before coming to us.
Date of Birth*
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Sex*—Please choose an option—MaleFemaleNot Specified
Do you have medical or dental insurance?*YesNo
Have you had your insurance for 12 months or more?YesNoN/A
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone Number*
Who is your GP?
At the present time are you taking any medication or tablets/or have you taken any medication or tablets during the last 6 months?*YesNo
If you have answered yes please provide more details
Are you taking any Vitamins, herbal supplements or homeopathic medication?*YesNo
Have you been under the care of a doctor: or in hospital during the past six months*YesNo
Have you experienced any allergic/unusual effects from any tablets, drugs, injections or anaesthetic?*YesNo
Please tick if you have had any of the followingHeart TroubleHeart MurmurArthritisAsthmaRheumatic feverJaundice or HepatitisAnemiaEpilepsyDiabetesBruise EasilyKidney problemsLow Blood PressureHigh Blood Pressure
Any other medical conditions? Please provide more detail
Do you have a bleeding problem, such as prolonged bleeding after surgery, anemia, or bruising?*YesNo
Have you had any prosthetic surgery? (e.g heart value or joint replacement)*YesNo
Are you taking any medications for Osteoporosis e.g. Fosamax, or an Aclasta Infusion?*YesNo
Are you HIV positive?*YesNo
Are you hepatitis "A" "B" "C" positive?*YesNo
Do you smoke?*YesNo
Are/could you be pregnant?*YesNo
Have you or any of your family or friends have travelled overseas recently?*YesNo
If yes, to which country have you / they travelled?
Do you have any individual requirements? If yes, please provide more details.
Religious, spiritual, cultural or family / Whanau*YesNo
Do you want your Extracted Teeth returned. Body parts: if your procedure requires the removal of a body part would you like it returned if this is possible?*YesNo
Is there anything else we need to know to help us plan your care? Please detail below. You will have the opportunity to discuss this with your nurse / surgeon prior to your surgery?*YesNo
How did you hear about us?*Referred by DentistReferred by GPReferred by InternetReferred by RadioReferred by Newspaper MagazineReferred by Yellow PageReferred by FriendsReferred by Other
Please review and confirm your answers.
We require 48 hours' notice for all cancellations or 30% of that appointment will be charged.
For insurance purposes, it may be necessary to release health information to your insurance provider to obtain your prior approval.
I acknowledge that my health information may need to be released to the insurance provider and give my informed consent for this to occur.I Accept