New Patient Form

Patient Information
Next of Kin
In case if an emergency whom should we contact?
Please indicate if different to next of kin.
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
Medical History

Daytime Sleepiness Evaluation
Epworth Sleepiness Scale
The Epworth Sleepiness Scale was developed and validated by Dr John Murray of Melbourne Australia. It is a simple self - administered questionnaire - widely used by sleep professionals in quantifying the level of daytime sleep. For the following situations, answer with one of the following numbers:

0. Would never dose

1. Slight chance of dozing

2. Moderate chance of dozing

3. High chance of dozing

How did you hear about us?
Keep Informed
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may effect my nex 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.


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