Online Patient Form - Marrickville

At Metro 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.

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

Click here for our privacy policy

Patient Information
Surname:* Title:
Given Name:* Date of Birth:*
Address:* Suburb:*
Ph (home):* Mobile Number:
Ph (work): Please select your preferred no.:
Name of DENTAL Private Health Fund (if any): Membership No.:
Patient Code:
Emergency Contact

In case of an emergency whom should we contact?

Name: Relationship: Phone:
Medical History

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

How do you rate your general health?
Who is your General Practitioner?:
Have you ever had facial injectables e.g. Botox, Dysport or Fillers?
Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify):
What medications including natural remedies are you taking?:
Dental History
How long is it since your last thorough dental examination?:
Please tick any dental concerns you have?
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.
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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.