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Patient Info
New Patient Questionnaire

New patient

Fill this in at home, not in the waiting room

Name: Eco Dental
Address: 136 Glebe Point Road, Glebe, NSW, 2037, AU
Telephone: (02) 9566 4400

Ten minutes now means your appointment starts on time and your clinician has read your history before you sit down. Everything here is confidential and covered by our privacy policy.

Leave this field empty

About you

Fields marked * are needed. The rest saves the front desk asking you at the door.

Title

MrMrsMissMsDrOther

First name * (required)

Surname * (required)

Date of birth * (required)

Occupation

How we reach you

We only need one number, but more is welcome.

Mobile * (required)

Home phone

Work phone

Which number suits you best?

MobileHomeWork

Street address

Suburb

Post code

Your cover

Health fund

Member number

Your doctor (GP)

In an emergency

Someone we can call if we ever need to.

Their name

Their phone

How you know them

How you heard about us

How did you hear about us?

Google searchYellowpages onlineYellow pages bookWebsiteAdvertisementsBillboardFriends or familyTVSomething else

Tell us where

If someone recommended us, who were they?We like to thank them — everyone who refers a patient gets a reward.

Medical history

Tick anything you have now or have had before. If you are unsure, leave it and we will ask.

Do you have, or have you had, any of these?

Heart diseaseAsthmaEpilepsyLung diseaseBlood diseaseDiabetesProsthetic heart valvesHeart murmurHepatitis A, B or CAids/HIVKidney diseaseLiver diseasePacemakerRadiation therapyRheumatic feverBone diseaseStrokeTuberculosisExcessive bleedingCancerChemotherapySmokingArtificial jointsSinus problems

Your health, continued

Any other illnesses?

YesNo

Please explain

Are you taking any medications?

YesNo

Please list them

Are you taking any vitamins or supplements right now?

YesNo

Please list them

Do you take, or have you taken, bisphosphonate medication?

YesNo

Medicines for osteoporosis such as Fosamax, Actonel or Prolia.

Have you been in hospital recently?

YesNo

Please explain

Allergies

Are you allergic to penicillin?

YesNo

Any other allergies?

Are you pregnant?

YesNo

How many months?

How we work

Would you like a holistic approach to your dental treatment?

YesNo

If you are not sure what that means, just ask us — it is not a test.

Do you keep a fluoride free lifestyle?

YesNo

Your teeth

What would you like to get out of your visit?Including nothing — a routine check is a perfectly good answer.

Last dental visit — years ago

…and months

Anything troubling you?

Tick as many as you like.

Are you experiencing any of these?

Sensitivity to hot or coldFood trapping between teethPain when chewing or eatingStaining of your teethDiscoloured fillingsChipped or rough fillingsBleeding gumsBad breathGrinding your teethHead or neck acheClicking or pain in jaw joints

Are you concerned about any of these?

Existing crowns, bridges or denturesAbility to eatGaps between your teethMissing teethCrooked teethSilver fillings (amalgam)Previous dental treatment

Anything that would make the visit easier

Before you finish

Payment is due on the day of treatment, unless your dentist agrees otherwise. We claim from your health fund on the spot with HICAPS, take card and cash, and offer interest-free payment plans through Care Credit. We do not accept cheques.

Please give us at least 24 hours' notice to cancel, or a fee may apply.

We send an SMS reminder the day before your appointment, but remembering it is up to you. Tell us if you would rather not get the reminder.

Are you happy for x-rays or photos of your teeth to be used for teaching or marketing?

YesNo

Saying no changes nothing about your treatment.

Are you happy for us to take your photo for your records?

YesNo

I agree to eco Dental collecting this information to treat me safely, and I have read the privacy policy. * (required)

In an emergency, or if anything here is urgent, please call (02) 9566 4400, and if you can't reach us, call 000, rather than waiting for us to read the form.

Prefer paper?

Download the form, print it, and fill it in at home. Bring it with you and we will enter it at the desk.

Download the form (PDF)

Why we ask

Medical conditions and medications change how we anaesthetise, what we prescribe and how a socket heals. It is not paperwork — it is the safety check.

Bring with you

Your health fund card
A list of current medications
Any X-rays from a previous dentist
Your Medicare card, for children

Rather not do it here?

Book first and bring the answers with you — the front desk will enter them, and the appointment still starts on time.

Request an appointment Call (02) 9566 4400