Patient Details
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
What is your gender
Email
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Phone
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(###)
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name
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First Name
Last Name
Phone
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(###)
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Relationship
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My regular dentist is (dentist and dental clinic's name)
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My regular hygienist is ( hygienist and dental clinic's name)
I was referred by (name of the dentist, hygienist or specialist)
Dental Injuries
ACC Related
Name of your family doctor
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Name of the medical centre
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Specialist ( e.g. Cardiologist for chest pain)
Have you had any allergies or side effects from medications, food, plasters or insects? Please list them.
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List all your current medications
including asthma or nasal sprays and over-the-counter treatments such as pain killers, antihistamines and antacids) and any that you have taken in the past 6 months. Please indicate what each is for.
What illnesses have you had in the past?
Have you ever had chest pain that could have been from the heart? Please give details.
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Have you ever been told that you have an abnormal heart valve or heart murmur?
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Do you have a history of acute rheumatic fever? YES / NO. If so, give details.
Have you ever had a blackout or ‘funny turn’? YES / NO. If so, give details.
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Are you ever troubled with pain or aching in the stomach or abdomen? YES / NO. If so, give details.
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Have you ever had jaundice or hepatitis? YES / NO. If so, give details
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Have you ever had abnormal bleeding or bruising? Do you bruise easily? If so, give details.
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Do you suffer neck ache or stiffness? YES / NO. If so, give details
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Have you any history of stress or anxiety? YES / NO. If so, give details.
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Do you suffer from headaches or pain in the face? YES / NO. If so, give details.
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Do you (or does anyone in your family) have diabetes? YES / NO. If so, give details.
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Females: Is there any chance you could be pregnant?
Have you ever been a smoker? YES / NO. If yes, at what ages did you start and quit and how much did you smoke at most?
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How many days a week do you drink alcohol?
Have there been any significant illnesses amongst your immediate family?
Are there any other health issues you wish to discuss? YES / NO (please provide more information if you do)
Reason for visit today: What concerns do you have about your gums and teeth? How do you feel about your gums and teeth?
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Does anyone in your family have periodontitis, or have lost teeth due to a gum infection?
Have you had gum treatment previously?
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Please indicate how often you use these products
Do you have any of the following?
Have you had a panoramic view /OPG xray taken in the previous 6 months?
(We normally take a panoramic Xray to screen for all new patients who hasn’t had one in the previous 6-12 months. This is to screen for any abnoramlities. If you have any questions please do not hesitate to ask your periodontist.)
Please Note
• We normally share your x-rays and other clinical records with your dentist. We also communicate with your dentist for continuity of care. Please advise if you would prefer not to do this.
• All patient correspondence will be sent via e-mail, please let us know if you wish us to send a hard copy your postal address.
• Upon registration you are enrolled in our clinical follow up list. Please notify us if you do not wish to be on this list.
• Standard consult fee is $477 incl GST and is approximately 60min. Short consult fee / re-evaluation fee is $201 to $413 incl GST and is approximately 20 to 30min. Small X-rays and the panoramic Xray are included in the consult fee.
• Full payment is required at the end of the appointment for all patients unless by prior arrangement. We accept Eftpos, most credit cards. All fees estimates are based upon the condition of your mouth at the time of assessment.
• We understand that sometimes it is necessary to change your schedule, we kindly ask that you provide a minimum of 48 hours notice should you wish to change or cancel an appointment. Otherwise a $60 non-attendance fee may be charged.
• All costs incurred in the recovery of overdue funds including but not limited to debt recovery charges and legal fees may be added to the balance of your account.
• It will be helpful if you bring your regular home aids and toothbrushes to each visit including your initial consult.
• Remember to provide a list of your current medications. If you are taking multiple medications, you may wish to contact your local pharmacy or your family doctor for a print out of your medications.
• We invite you to visit website www.periocare.co.nz for more information regarding your first visit.
Digital Images of your teeth and face may be required for planning your treatment. These images are confidential and held securely on our server.
Do you consent to using these images for teaching/information purposes?
Signature
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