Make an appointment

Make an appointment with your dentist

Please enable JavaScript in your browser to complete this form.

Personal details

Date of Birth
Do you have a private health fund with dental cover ?

Guardian details (if patient is under 18 years of age)

Language and background

Are you of Aboriginal or Torres Strait Islander
Is English your preferred language?

Question

Are you currently receiving treatment from a doctor?

List details (if applicable)

Known allergies (e.g., medications, penicillin, latex)
Previous reaction to local or general anaesthesia?
Are you currently pregnant? If yes, How many weeks
Do you smoke or vape?
Do you use any recreational drugs or other substances?
Have you been advised that you need antibiotic coverage prior to receiving dental care?
Do you use any mobility aids (eg. wheelchair, walker, cane)?
Do you have any dental fears or anxiety?
Have you had any hospital stays, surgeries, procedures in the last 12 months?

DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING MEDICAL CONDITIONS?

(Please tick the appropriate box)

DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING MEDICAL CONDITIONS?

PAYMENT METHOD

PAYMENT METHOD

REFERRAL INFORMATION-Please tell us how you heard about us

REFERRAL INFORMATION-Please tell us how you heard about us

DENTAL CARE RIGHTS AND RESPONSIBILITIES

DENTAL CARE RIGHTS AND RESPONSIBILITIES

CONSENT FOR SERVICE

  • I understand, to the best of my knowledge, I have provided accurate information relating to my health, and if any changes arise, I will notify the dental provider as soon as possible.
  • I consent to the performing of dental and surgical procedures as may be deemed necessary or advisable, and I will assume responsibility for the fees associated with these procedures.
  • I consent to share my dental information with specialists or other providers if needed.
  • I am aware payment is due on the day of service.
  • I understand that Full Care Dental requires at least 24 hours' notice should I need to cancel my scheduled appointment, and that a cancellation fee of $50 per 30 minutes or $100 per 60 minutes may be charged.

*A copy of Full Care Dental Privacy Policy is available upon request