Patient Details

Given Name*:
Mobile Number:
Email Address*:

Medical & Dental History

Q1: Please select your age...*
18-2526-4041-55over 55

Q2: Please select your gender*
MaleFemalePrefer not to say

Q3: The number of times you have visited the clinic in the past year*
OnceTwice3 times4 timesover 5 times

Q4: I am submitting this application for...
Treatment for myselfTreatment for my child

Q5: Are you currently taking any drugs or medication?*
No, I am currently not taking any drugs or medicationYes, I am currently taking drugs or medication
If so, please list all drugs you are taking:

Q6: Do you have any allergies? (eg. Latex, Penicillin, Local anesthetics)

Q7: Are you in a High Risk Group for infectious disease?* (eg. HIV, Hepatitis, Creutzfeldt Jacob Disease)
No, I am not in a High Risk GroupYes, I am in a High Risk Group for infectious disease
If so, please elaborate:

Q8: Do you smoke?*
No, I am a non-smokerYes, I smoke
If so, how many cigarettes do you consume daily?

Q9: Do you have artificial hip, knee, heart valve or other prosthetics?*
No, I don't have any artificial prostheticsYes, I have artificial prosthetics

Q10: Do you require antibiotic cover prior to dental treatment?*
No, I don't require antibiotic coverYes, I may require antibiotic cover prior to dental treatment

Q11: Are you with a Dental Health Fund - if so, which Fund are you with?

Great, a little more about your dental experience and any areas you'd like to focus on with our dental team ...

Q12: How long has it been since your last dental visit?*

Q13: What was done for you at your most recent dental visit?*

Q14: On a scale of "1-10", with "10" being "completely relaxed", how comfortable are you about visiting the dentist?*

Is there anything we can do to make your visit more pleasant?
What is your biggest concern about visiting the dentist?

Q15: Do you suffer from, or get any of the following, conditions?* (please select as many that are applicable)
Headaches or MigrainesClench your teeth during the day or nightGrind your teeth during the day or nightChewing or jaw movement problemsSnoringGums bleed easilyBad breath or taste in mouthDry mouthSensitive teeth (please specify below)

If you selected "Sensitive teeth" above, what type of sensitivity are you experiencing? (please select as many that are applicable)

Q16: Have you ever whitened your teeth (also known as teeth bleaching)?
Are you interested in whitening your teeth?
Are you interested in straightening your teeth?
Have you previously had orthodontics?
Is there anything about your smile that you would like to change?

Have you noticed any changes in:
The colour of your teeth?*
Wrinkled on your face or chin?*
Position of teeth?*

Is there anything else about your smile or facial complexion that you'd like to share with us?

We're almost done ...

At Bacchus Marsh Dental House, our practice respects every patient's right to privacy. We collect this information to help us to deliver a comprehensive dental treatment experience to you - we believe that every patient deserves a great smile and we strive to ensure that your visit to our clinic is enjoyable as possible, set within a comfortable and caring environment.

Personal information collected here and during your treatment ongoing is used solely to enable our role as your healthcare professionals. We will treat your details confidentially, and limit any disclosure of this information only to persons involved with your treatment and the administration of this practice. Sometimes we may need to share your information, such as when processing payments with your Health Fund, or when liaising with your GP, for example.

Please note that your patient history, treatment records and X-ray files will be kept in our clinic under a secure digital vault. If you request an explanation of our records or a written summary, feed may apply to these services. If you have a change in personal details, or require any changes to our records, please advise our reception to update these for you as soon as possible. If you have any queries or concerns about how your personal information is handled, please don't hesitate to speak with us about it.

Home Address*:
Where do you work / who is your employer?
What is your occupation?

In case of emergency, please provide a contact person not living with you:
Emergency Contact's Name*:
Their relationship to you*:
Emergency Contact's Mobile*:
Emergency Contact's Address*:

How did you hear about us?

If you selected Other:

Yes, I give permission to Bacchus Marsh Dental House to use my email address for keeping in touch and marketing communications
Yes, I understand any before and after photos taken during my treatment may be used for staff training, case presentation and / or displayed on the website (your identity will be kept confidential)

Today's date (DD/MM/YYYY)*:

By submitting this form you accept that all information is collected confidentially in accordance with our Privacy Policy and website Terms of Use