Address: 187 Broadway Avenue, Palmerston North, Manawatu 4410
P: (06) 358 5386 | F: (06) 359 4193 | E: click here

New Patient Form

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 for our “Personal Information, Privacy and your Dentist” document. Click here for our privacy policy.

Patient Information
Surname:* Given Name:*
Date of Birth:*
Address:* Suburb:*
Ph (home):* Mobile Number:
Ph (work): E-mail:*
Occupation: Company:
Emergency Contact

In case of an emergency whom should we contact?

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.

Medical History

Please tick all that apply.

Infectious Diseases?: Joint Replacement?:
Pregnant? Due Date: Hepatitis? Specify Type:

Healthcare Professional Details

Name of your Doctor/GP?: Name of Previous Dentist?:
Please list any medication you are currently taking:
Have you ever had an unfavourable reaction to anesthetic? Are you happy with the appearance of your teeth?
If there is an accidental injury to our staff during handling of your used instruments, do you agree to a confidental blood test?
Dental Allergies

Please tick all that you are allergic to.

Other? Please specify:
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.


To see the patient form, please open this page on your computer.