Patient Enrolment Form

    Personal Details:







    Contact Details:







    Emergency Contact Person:




    How did you hear about us? (Please tick where applicable)

    Friend (please advise their name below)Word of mouthGoogleFacebookInstagramOther: (please advise below)



    Medical Information:




    Medical History:


    YesNo

    YesNo


    YesNo


    YesNo


    YesNo


    Heart problems / pacemakers / angina / stroke / heart murmur / open heart surgeryRheumatic feverJaundice / liver diseaseAsthmaHigh blood pressureKidney problemsAnaemiaGastric problemsBronchitis or chest problemsDrug dependenceSinus / Hay feverSevere headachesHepatitis- specify type A, B, CDepressionEpilepsy / fainting attacks / blackoutsCold soresDiabetesArthritisRadiotherapyAllergiesExcessive bleeding / bruisingProsthetic surgery (heart valve, hip, knee replacement etc.)CancerOsteoporosisTaking or have taken FosamaxHIV/AIDSOther (Please specify)



    YesNoWish to discuss with the dentist

    Please be advised by signing this document you agree that any accounts remaining unpaid without being discussed and approved by the dentist may be sent to debt collection where further action will be taken to collect the amount owed which may include but is not limited to further costs being added.