Gentle and caring teeth & gum health maintenance.

Patient Registration Form

In order to expedite the arrival process at Surrey Dental, we’ve provided an electronic version of the ‘Patient Registration Form’.

Complete this form online, ahead of your arrival to ensure you wait time at the commencement of your appointment is minimised.

Please take care to fill out this form completely. We rely on all your information to be able to provide you with appropriate dental services.

* Indicates required fields.

Preferred Title *   
 
First Name *   
 
Last Name *   
 
Preferred Name    
 
Home Address (Inc. Suburb & Postcode)   *   
 
Home Phone *   
 
Work Phone *   
 
Mobile *   
 
Email Address *   
 
Date of Birth (DD MMM YYYY) *   
 
Would you like to receive an appointment reminder? *   
 
Would you like to receive newsletters and notification of special offers? *   
 
If you are under 18 years of age, please state Father / Mother / Guardian’s name      
 
If relevant, please state your Carer name    
 
If relevant, please state your Carer Phone    
 
Emergency contact name *   
 
Emergency contact Phone or Mobile *   
 
Please provide the name of your Medical Doctor:    
 
Your Medical Doctors phone number:    
 
Who is responsible for the account? *   
 
Do you have Private Health Insurance? *   
 
Private Health Fund    
 
Private Health Policy Number    
 
Private Health Ref. Number    
 
Do you have a Healthcare / Pension Card? *   
 
Healthcare / Pension Card Number    
 
Are you eligible for the Child Dental Benefits Schedule (CDBS)? *   
 
Medicare Card Number    
 
Medicare Ref. Number    
 
Department of Veterans Affairs’ Card Number    
 
Is this consultation related to Workcover or a Work related injury or Transport Accident?     *   
 
Are you Aboriginal or Torres Strait Islander (for health related issues)? *   
 
Are there any cultural issues that we may need to be aware of? *   
 
If applicable, please state cultural issues    
 
How did you hear about Surrey Dental?    
 

Medical History
Have you had or do you suffer from any of the following?
 
High Blood Pressure *    YesNo
 
Heart Ailment: *    YesNo
 
Rheumatic Fever: *    YesNo
 
Asthma, chest or breathing problems: *    YesNo
 
Tuberculosis: *    YesNo
 
Stomach or bowel problems (eg Ulcer): *    YesNo
 
Kidney Disease: *    YesNo
 
Diabetes: *    YesNo
 
Thyroid Problems: *    YesNo
 
Excessive Bleeding or Blood Disorder: *    YesNo
 
Epilepsy: *    YesNo
 
Hepatitis: *    YesNo
 
AIDS/HIV: *    YesNo
 
Bone Disorders or Disease: *    YesNo
 
Do You Smoke: *    YesNo
 
If yes (to Smoking), number per day:    
 
If yes (to Smoking), would you like to stop:     YesNo
 
Please list previous illnesses (separate by comma):    
 
Would you like to discuss these problems in private with a dentist? *    YesNo
 
Do you have: Artificial Hip, Heart Valve or Prosthetic Implant? *    YesNo
 
Have you ever had problems with Dental Treatments? *    YesNo
 
Are you presently under Medical Care? *    YesNo
 
Are you taking drugs, medicines or tablets? *    YesNo
 
If yes, (taking drugs, medicines or tablets), please list:    
 
Female Patients: Are you Pregnant?     YesNo
 
Do you have allergies? *    YesNo
 
List any medicines or products you are allergic to (eg: Penicillin, Latex, etc):    
 
Do you wish to provide any additional comments?  

I certify the information provided is correct.

In the input box below, please enter the code displayed here:      captcha

Privacy Policy – We collect the information set out above in order to provide you with dental services. We will keep your information secure and confidential. If necessary, we may pass your information on to other health practitioners for a second opinion or referral purposes. We may also be required by law to provide your information to outside agencies. Our complete Privacy Policy is available at reception.

Location – Surrey Hills Practice

SURREY DENTAL
Unit 2, 109 Union Road,
Surrey Hills, Victoria
Australia, 3127

For directions to the dental clinic of Dr Susan J Poulsom, Surrey Dental, please visit our Clinic Location page!

Location – CBD Practice

TEETH HEALTH LIFE
4th Floor, 175 Collins Street
Melbourne, Victoria
Australia, 3000

For directions to our CBD Practice, please visit the Teeth Health Life Website