New Patient Information Form - Adelaide Paediatric Dentistry

IMPORTANT

Does your child have a fever, cough, or difficulty breathing*

Yes
No

Have you or your child been in contact with any suspected or known cases of COVID-19*

Yes
No

Patient information

Surname*

First Name*

Date of Birth*

Have you been to see us before?

Yes
No

Preferred method of contact for Teleconsult if required*

Address*

Street Address Address Line 2 Suburb State Postcode Country

Parent details

Phone number*

Email*

Alternative phone number

Parent 1*

First Name (Parent 1)*

Surname (Parent 1)*

Parent 2

First name (Parent 2)

Surname (Parent 2)

Legal guardian*

Both parents
Other

Do any other family members attend this surgery?

Has a written referral been provided?*

Yes
No

Please provide details

Private Health Fund

Do you have Private Health Insurance

Yes
No

Health Fund Name

Membership Number

Patient Reference

Medicare details

Medicare Number*

Patient Reference*

Expiry (mm/yy)*

Medical History

Name of family doctor

Has your child had a previous General Anaesthetic?*

Yes
No

If YES, were there any complications?

Please list any operations your child has undergone

Is your child taking any medications?

Yes
No

Please list the medications your child is currently taking

Does your child have any allergies, including drugs, medications and latex?

Yes
No

Please specify

Are your child’s immunisations up to date?*

Yes
No

Please tick the following that apply to your child

Does your child have any other condition not listed?

Dental History

Do you have any concerns about your child's teeth?*

Is your child currently experiencing any pain?*

Yes
No

Details of your child's current pain

Did your child have an accident and injure their teeth?*

Yes
No

Date of accident

How did the accident occur?

Where did the accident occur?

Attach 5 photos

Patient’s upper right back teeth

Max. file size: 512 MB.

Patient’s upper left back teeth

Max. file size: 512 MB.

Patient’s lower left back teeth

Max. file size: 512 MB.

Patient’s lower right back teeth

Max. file size: 512 MB.

Front teeth with lip lifted

Max. file size: 512 MB.

Agreement

Full Name*

By submitting this for I acknowledge, to the best of my knowledge, all the preceding answers are true and correct.*

I agree

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Step 1. Photos saved on your phone/computer

Step 2.

IMPORTANT

Patient information

Parent details

Private Health Fund

Medicare details

Medical History

Dental History

Attach 5 photos

Agreement

Teleconsultation Patient Information Form