New Patient Form

At Burwood Dental we strive to provide you with the highest possible care. To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present.  Without this information it is difficult for your dentist or hygienist to plan your care properly.

Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation. If you would like any further information about how we use and protect your personal information, please ask one of our staff. Click here for our privacy policy.

If you don't wish to complete the form online, you can download the PDF version here.

Patient Information
Title:
Surname:* Given Name:*
Preferred Name: Date of Birth:*
Address:* Suburb:*
Postcode:*
Ph (home):* Mobile Number:
Ph (work):
E-mail:*
Vet Affairs Vet Affairs Card No:
VA Expiry Date:
Name of Private Health Fund (if any): Position No on Card:
Occupation: Employer Name:
Next of Kin
Name: Relationship: Phone:

In case of an emergency whom should we contact?

Please indicate if different to next of kin.

Name: Relationship: Phone:
Reminder System

We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.

Dental History
How long is it since your last thorough dental examination?:
Please tick any dental concerns you have?
Medical History
How do you rate your general health?
Who is your General Practitioner?:
Telephone:

Have you had or are you suffering from any of these? (please tick)

:
Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify):
What medications including natural remedies are you taking?:
How did you hear about us?
Referral Source:    
Keep Informed Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
Consent for Services

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.

 

reception@bwdental.com.au

Surgery Opening Hours

Mon: 8am – 6pm
Tue & Wed: 8am – 5pm
Thu & Fri: 7am – 5pm
Sat: 8am – 1pm


Our Location

144 Burwood Rd,
Burwood NSW 2134

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Parking

Parking available.

Click here for details.

New Patient
Offer $195

Comprehensive Dental Assessment (valued at $300) includes:
  • Comprehensive examination
  • 2 check up x-rays
  • Full mouth panoramic x - ray (if required)
  • Treatment planning
Click here to find out more

Our E-Book
On Sale

Dr Eli Gold has written a book ‘HOW TO PUT YOUR DENTIST OUT OF BUSINESS’, providing quick & easy tips & invaluable information for pregnant women, babies, children, teenagers, adults & seniors.

Buy it Now

Corporate
Dental Program

Along with Dental Care Network ™ we are offering the Corporate Dental Program, a zero-cost, zero-admin employee benefit scheme which provides you with exclusive benefits for dental treatment if you are an employee of one of our partnered corporate programs.

Click here to find out more