CALL 3378 0033
MAKE AN APPOINTMENT
PERSONAL DETAILS FORM
Please complete these questions as completely as possible. It will assist us greatly in our efforts to provide the best dental treatment for you,. All information is strictly confidential but will be transmitted to Clubb Dental via email. Please let Dr Clubb Know if there is anything you do not wish to answer in writing. Or alternatively you can print out this form and bring it with you to our upcoming appointment.
Indicates required field
Date of Birth
Complete address if your address has changed since your last patient update form
Complete if your Suburb has changed since your last patient update form
Do you have Dental Insurance?
If yes - Health Insurer Name?
If Yes - Health Insurer Number & Series Number?
Emergency Contact: Name and Phone number
Yes / No
How do you prefer to receive checkup reminders?
Do you give us permission to use your unidentifiable photos for educational and marketing purposes? eg Before and After photos
How did you find us?
Recommended by existing patient
Driving by Practice
Online Search / Google
If you were recommended by existing patient, who was it? (so we can thank them)
Anything else you would like to discuss with Dr Steven or Dr Tijana at your appointment. ie Dental problem, whitening or mouthguard
Please list any medications you are currently taking
If you are not taking any medications please write "nil" in this section
Please list any known allergies
If you do not have any known allergies please write "nil" in this section
Do you have or have you ever suffered from any of the following conditions?
High Blood Pressure
Asthma / Lung Conditions
Females - Are you pregnant?
None of the above
Please mark any medical conditions that you previously or currently have suffered from or check the "None of the above" box
Anything else about your medical history Dr Steven or Dr Tijana should know about?
When was your last dental treatment?
What is the purpose of today's visit?
Please note that we will still send you a confirmation SMS 48 hours before your appointment.
Join our email list to receive our latest blogs and special offers.
SUBSCRIBE TO EMAIL LIST
Single Visit Crowns
Why is Clubb Dental not a Preferred Provider?
© COPYRIGHT 2021 ALL RIGHTS RESERVED.