Add: Suite 5, Prof Suites Lynden Court, Chartwell, Hamilton, 3210 | P: 7855 4904 | E: click here
Add: 17B Rototuna Shopping Centre, Rototuna, Hamilton, 3210 | P: 7853 0050 | E: click here

Online Patient Form

As a new patient we need to get to know you and your medical and dental history so that we can gain a comprehensive understanding of your current and past oral health to provide you with the highest quality treatment. For this reason we will request that you complete a New Patient Form. This can be done in just a few minutes at our practice, prior to your appointment.

However, for your convenience, we have also made this form available online, so the answers will be sent straight to our practice. Alternatively, you can also download to form to complete at a time that suits you. Then, simply fax the completed form back to us or bring it to your appointment.

Click here to download our Chartwell New Patient Form PDF.

Click here to download our Rototuna New Patient Form PDF.

Practice Location

Which practice location are you visiting?			Chartwell Rototuna

Patient Information

Title:
Surname:*		Given Name:*
Preferred Name:		Date of Birth:*
Address:*		Suburb:*
Postcode:*
Ph (home):*		Mobile Number:
Ph (work):
E-mail:*
Who is your Medical Doctor?:		Phone:
Occupation:		Employer Name:

Next of Kin

Name:

Relationship:

Phone:

In case of an emergency whom should we contact?

Please indicate if different to next of kin.

Name:

Relationship:

Phone:

Reminder System

We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.

SMS

Mobile

Hm Phone

Work Phone

E-mail

Allergies and Medication

Are you taking and prescription or non-prescription medication, pills or inhalers? If yes, please list:
Have you ever had any allergies to medicines, or other substances (such as latex)? If yes, please list:

Dental History

How long is it since your last thorough dental examination?:

Medical History

Have you ever had any of the following? (Please tick)

Heart murmur?

Open-heart surgery?

Other heart trouble/stroke?

High or low blood pressure?

Asthma?

Rheumatic fever?

Chest/lung/breathing problems?

Sinus/hay fever

Diabetes?

Eczema?

Tuberculosis?

Epilepsy?

Radiotherapy?

Bruising/ bleeding problems?

Other infectious disease?

Depressive illness/ anxiety?

Smoker?

Arthritis?

Do you have any artificial or prosthetic joints?

Yes No

Have you ever had contact with: HIV, Hepatitis B or C virus?

Yes No

Have you ever been given or are currently taking the drug Fosamax (Bisphosphonates)?

Yes No

Have you ever experienced excessive bleeding or bruising?

Yes No

Have you ever had an unfavorable reaction to local anaesthetic?

Yes No

Women: Are you pregnant or breast-feeding? If pregnant, how many weeks?:

Are there any other health matters you need to talk to the dentist about?

Yes No

How did you hear about us?


Referral Source:
Referred by another patient who?
Referred by staff who?
Other
Company Referred By who?

Keep Informed Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.

Consent for Services Ticking this check box certifies that:

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.

Corporate Dental Program

Online Patient Form

To complete or download our online patient form before your first appointment.

Ask Our Dentist

Our experienced dental team is happy to answer any questions you may have about your dental health and care. Educating our patients on their dental health is important to us. Click on the link below to ask us your questions.