Patient Questionnaire

Are you receiving any medical treatment at the present time?
Have you been a patient in hospital during the past 2 years?
Tick any of the following which you have had:
Are you apprehensive of Dental Treatment?
Are you taking any tablets, capsules, medicines or drugs?
Have you had any allergies to medicines that you are aware of?
Have you had any prosthetic surgery? (eg heart valve or hip replacement)
Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?
Have you ever had contact with the HIV virus or Hepatitis B virus?
Have you ever had a reaction to an anaesthetic?
Women - are you pregnant now?
Is there any family history of diabetes?
Do you like the appearance of your teeth and your smile?
Are your teeth all in alignment (straight)?
Do you have spaces that you don't like?
Do you like the colour of your teeth?
Do you like the shape of your teeth?
Are your teeth chipped, protuding or hidden?
Are there old fillings or dental work that you don't like looking at?
To ensure your visits with us are the most pleasant, please tick any of the following which may apply to you:

Thank you for choosing us as your dental health care provider. To maintain the practice operation and prevent potential misunderstanding, we ask patients to adhere to the financial arrangements regarding their treatment. Payment is required at the time services are rendered. We can offer extended payment for some treatments e.g. orthodontic treatment, please ask our staff for details prior to commencing treatment. Overdue accounts will incur fees. Fees also apply for broken appointments without proper notification. I consent to Greville Dental collecting and keeping information about my health for the purpose of making sure that I receive appropriate care and treatment, and for associated administrative tasks. I understand my relevant health information will be stored by Greville Dental, and that I am entitled to request access to and correction of my health information. I agree to provide this information voluntarily.