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Patient Referral
New Patient Registration

New Patient Registration

Web Site

Title:

First Name: *

Last Name: *

Date of birth: *

Email Address: *

Mailing address:

Occupation: *

Phone Number: *

Cellphone Number:

Preferred form of contact *

email phone cellphone post

Emergency Contact

Name of Emergency Contact: *

Relationship: *

Contact Number: *

Referring Doctor

Regular Dentist:

Medical GP:

Medical Questionnaire

Are you currently taking any medications, tablets, lotions or creams? *

Yes No

Are you currently taking any vitamins, homeopathic medications or herbal supplements? *

Yes No

Are you currently receiving medical treatment? *

Yes No

Do you have any allergies or unusual effects from any medications, drugs, materials or foods? *

Yes No

Please tick if you ever had any of the following:

Heart Issues:

High blood pressure

Low blood pressure

Angina

Heart murmur

Prosthetic valve

Rheumatic Fever

Pacemaker

Other

Lung Issues:

Asthma

Emphysema

COPD

Sleep Apnoea

Other

Bleeding Issues:

Previous clots/DVT

Blood thinners

Anaemia

Uncontrolled Bleeding

Family history

Other

Other Medical Issues:

Diabetes

Epilepsy

Fits or Faints

Kidney troubles

Hepatitis

Jaundice

Stomach/gut ulcers

Prosthetic joints

Neck/back problems

Arthritis

Stroke

Other

Do you smoke? *

Yes No

Could you be pregnant? *

Yes No

Do you have any specific cultural, spiritual, religious or family/whanau needs that we should be aware of? *

Yes No

Name of person completing this form: *