Please click below to view and download patient information documents.

Online Form

    Salutation (required)

    Surname (required)

    First Name (required)

    Address (required)

    Suburb (required)

    Postcode (required)

    Email Address (required)

    Date of Birth (required)

    Home

    Mobile

    Work

    Medicare Number

    Medicare Ref

    Nearest Emergency Contact

    Emergency Contact Number

    How would you like to receive your Dental Recall? (required)

    Person responsible for account (if other than self)

    Private Health Fund

    Private Health - Dental Extras?

    Private Health Fund Member Number

    Private Health Fund Member Ref Number

    Have you had or do you have any of the following medical conditions? Select Yes or No

    Heart Murmurs (required)

    Heart Attack (required)

    Asthma (required)

    Rheumatic Fever (required)

    Epilepsy/Fits (required)

    Females Only: Are you pregnant at this time?

    Does this patient have special needs? (required)

    Blood Pressure: Low / High (required)

    Cardiac Surgery of Pacemaker (required)

    Diabetes (required)

    Hepatitis (required)

    If Yes, hepatitis type

    If Yes, hepatitis year

    Transmissible Disease (TB/HIV) (required)

    Are you allergic to:

    Penicillin (required)

    Latex (required)

    Others

    Are you taking Anticoagulant (blood thinning) medication? (required)

    Has your medical practitioner specified you require Antibiotic Cover for dental treatment? (required)

    Have you had lap band surgery? Yes No Is your weight over 120kg? (required)

    Are you currently or have you had treatment for Osteoporosis? (required)

    Do you Smoke? (required)

    Are you taking any Drugs or Medication at present? (required)

    If Yes, please list

    Are you currently having or have you had treatment for Cancer OR Bisphosphonates? (required)

    If Yes, please select one

    Have you previously had ANY reaction to Dental Procedures? (required)

    Name of your General Practitioner and Surgery (required)

    Are you Aboriginal or Torres Strait Islander? (required)

    How did you hear about Moonah Dental Centre?
    Yellow Pages onlineGoogleFacebookFriends/FamilyYellow Pages BookShopper DocketBus AdvertisementBillboard SignDental ReferralHealth FundOther (please specify below)

    If Other, please specify

    By clicking below I declare that the information provided is true and correct (required)
    My information is true and correct

    PRIVACY ACKNOWLEDGEMENT
    1. We acknowledge our obligation to you under the privacy act 1988 (as amended December 2014)
    2. Personal information collected from you will be used primarily to insure that you receive optimal care, but may be used for other purposes. 3. The use of your personal for a limited number of
    purposes, e g to provide care to you, does not require your consent, if we want to use the information for other purposes we will ask you for your consent. 4. In the event of default, the Customer will
    be liable for the collection costs incurred.