New Patient Offer $195

Comprehensive Dental Assessment (valued at $435) includes:

Comprehensive examination
2 check up x-rays
Full mouth panoramic x - ray (if required)
Treatment planning

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Patient Referral Reward

It gives us great pleasure knowing so many of our patients have recommended our high quality service to family, friends and colleagues. We appreciate this compliment and have sent out many rewards to our patients to say thank you for the referrals.

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Corporate Dental Program

Asquith Dental along with DENTAL CARE NETWORK ™ is offering the Corporate Dental Program which provides you with exclusive benefit of a complimentary $100 service voucher to be redeemed for dental treatment if you are an employee of one of our partnered corporate programs.

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Patient Information

Title:
Surname:*		Given Name:*
Preferred Name:		Date of Birth:*
Address:*		Suburb:*
Postcode:*
Ph (home):*		Mobile number:
Ph (work):
E-mail:*
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.
Vet Affairs	Gold White	Vet Affairs Card No:
VA Expiry Date:
Name of Private Health Fund (if any)		Position No on card:
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

How did you hear about us?

Referral Source:	Please Select Yellow Pages Yellow Pages online Search Engine DENTAL CARE NETWORK TM Corporate Dental Program Practice Website Signage New Patient Offer Card Advertising Referred by a friend Other Patient Referral Staff Referral
Referred by another patient who?
Referred by staff who?
Other
Company Referred By who?

Dental History

How long is it since your last thorough dental examination? 0-6 months 1 year 2 year 3 year longer

Please tick any dental concerns you have?

Toothache Sensitive teeth Bleeding gums Loose teeth Bad breath Dry mouth

Missing teeth Unsatisfactory denture Rapidly decaying teeth Lost filling/cavity Grinding/clenching teeth Worn, broken teeth

Pain in face or jaw joints Sounds from joint Difficulty chewing Discoloured teeth Bad appearance of teeth Do you, or have you ever smoked?

Medical History

How do you rate your general health? Excellent Good Poor Fair
Who is your general practitioner?
Telephone:

Have you had or are you suffering from any of these?  (please tick)
Heart Trouble / Surgery Cardiac Pacemaker High blood pressure Low blood pressure Diabetes Hepatitis Rheumatic Fever Arthritis Thyroid trouble Epilepsy Sleep Apnoea Stroke Stomach or digestive condition/reflux Osteoporosis	Nervous Disorders Asthma HIV/AIDS Liver or kidney disease Are you or could you be pregnant Excessive or prolonged bleeding Radiation or chemotherapy Eating disorder Prosthetic implant/joint replacement Organ or bone marrow transplant Steroid therapy Other (specify) Do you smoke?
Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify)
What medications including natural remedies are you taking?

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.

Any surgical or invasive procedure carries risks. Before proceeding with a surgical or invasive procedure, you should seek a second
opinion from an appropriately qualified health practitioner.

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