Welcome to Caring4Smiles Dental Group.

Below is our New Patient Intake Form.
We require the following information prior to any dental treatment.
All new patients MUST complete this form.
We must review your information every 2 years.
Your details are held as CONFIDENTIAL.
If you have a dental emergency, please advise us immediately.

New Patient Form

Updated June 2026

Step 1 of 11

This field is for validation purposes and should be left unchanged.

Name(Required)

First Middle Surname

Date of Birth(Required)

Day

Month

Year

How may we address you?(Required)

Mr.

Mrs.

Ms.

Master

Miss

He/Him

She/Her

They/Them

Please circle as applicable

Address

Home Address(Required)

Street Address Address Line 2 City Post Code

Is your postal address different to your home address?(Required)

Yes

Postal Address

Street Address Address Line 2 City Post Code

Communication Preferences

When making contact, do you prefer(Required)

Select exactly 2 choices.

Text Message (SMS)

Phone Call

If we need to contact you through text message (SMS) or phone call, which is the best number to reach you(Required)

Home Phone

Work Phone

Mobile Phone

Do you consent to use communicating with you via text message (SMS) and email?(Required)

Yes

To save our planet, may we email all invoices and receipts to you?(Required)

Yes

Contact Email and Phone Numbers

Email(Required)

Home Phone

Work Phone

Mobile Phone

Emergency Contact Information

Emergency Contact Name(Required)

First Surname

Their relationship to you(Required)

Their Phone Number(Required)

Do you give us consent to discuss any emergency with your next of kin?(Required)

Yes

Your Dental History

When was your last dental visit?

Approximation is fine.

Are you anxious of dental visits?(Required)

Yes

Is your visit to the dentist today an emergency?(Required)

Yes

What is the reason for your visit?(Required)

Do you experience bad breath?(Required)

Yes

Do your gums bleed?(Required)

Yes

What is your main concern about your teeth?

Past Dental Records

Do we need to retrieve your previous dental records from another dental practice?(Required)

Yes

Do you give us consent to contact your previous dentist to request your past dental records?

Yes

What is the name of the Practice

Name of the practice where we need to retrieve your dental records.

Dental Practice Address

Street Address Address Line 2 City Post Code

Dental Practice Phone Number

Dental Practice Email Address

Your Medical Practitioner

Name of your Medical Practitioner

First Surname

Medical Practitioners Phone Number

Medical Practitioners Address

Street Address Address Line 2 City Post Code

Medical History

Your NHI Number

Are you receiving any medical treatment at the present time?(Required)

Yes

Do you have any bleeding disorders?(Required)

Yes

Please specify your bleeding disorder(s)

Do you take Aspirin/Warfarin or any blood thinning medication?(Required)

Yes

Please list out all blood thinning medication you are taking

Please list any other medication/drugs you are currently taking

Do you have any allergies to any of the following?

Medication

Anaesthetic

Drugs

Metals

Check all that apply

Please list any/all allergies that you have

Do you have an artificial or prosthetic joint or had a recent major surgery?(Required)

Yes

Please specify your artificial/prosthetic joint or recent major surgery

Have you ever had a test for HEPATITIS/HIV/AIDS?(Required)

Yes

What was the result of your test for HEPATITIS/HIV/AIDS?

Positive

Negative

Do you smoke or vape?(Required)

Yes

Please tell us approximately how long you've been smoking and much do you smoke per day?

FEMALES: Are you currently pregnant?

Yes

How many weeks along are you?

What is your due date?

Day

Month

Year

Have you had any of the following?

Rheumatic fever

Arthritis

Anaemia

Gastric problems

Bronchitis

Heart condition

Depressive illness

Diabetes

Drug dependence

Liver disorder

High blood pressure

Severe headaches

Kidney disease

Hepatitis A/B/C

Anxiety

Asthma

Epilepsy

Cold sores

Cancer

Check all that apply

Are there any other aspects concerning your health you think your dentist should know about?

Our Terms and Conditions

Consent(Required)

I agree to the Communication Terms and Conditions below:

We both must agree on the lines and speed with which we will communicate to make, change, or confirm your dental appointment. We will respond to your communication immediately or within a couple of hours during busy periods of our day and we expect that you will reply to our txt / email / phone calls in a timely manner. After we close, messages will be attended to on the next business day.

Consent(Required)

I agree to the Payment and Financial Terms below:

Payment for all treatment and products is required at the time of your dental visit. We do not send out monthly statements or invoices. We accept payment by MasterCard / AMEX / VISA / Eftpos. Accounts that remain unpaid after 45 days are sent for collection unless special arrangements have been made. Collection fees and legal charges are levied by the collection agency and added to your account. Our practice can assist you with finance options through Q-Card. Ts & Cs, credit criteria & their fees apply.

Consent(Required)

I agree to the Rescheduling and Cancellation Terms below:

Your confirmed dental appointments are a contractual agreement between you and us, for a specific day and time. We understand that emergencies can occur so if for any reason you need to change a pre-booked & confirmed dental appointment, we require a minimum of 24 hours’ notice during our working hours Monday to Friday, so we can reallocate your appointment time to another patient in need. Failing this, we levy a late cancellation fee of $120 per hour booked, to cover costs.

How did you hear about us?

How did you find out about Caring4Smiles Dental?

Thank you for joining our practice.

Who can we thank for referring you?

Welcome to Caring4Smiles Dental Group.

New Patient Form

Address

Communication Preferences

Contact Email and Phone Numbers

Emergency Contact Information

Your Dental History

Past Dental Records

Your Medical Practitioner

Medical History

Our Terms and Conditions

How did you hear about us?

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