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(07) 3343 2100 1403 Logan Rd, Mt Gravatt4122 QLD

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(07) 3343 2100
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Patient Form

"*" indicates required fields

Welcome To Central Dental

Please take the time to fill in this form accurately, we ask you for information about your general health to help us treat you safely. All information and any images taken of you will be kept strictly confidential by the dentist caring for you.

Title*

First Name*

Last Name*

Date of Birth*

DD slash MM slash YYYY

Postal Address*

Suburb*

Post Code*

Occupation

Contact Details

Home

Mobile*

Work

Email*

Preferred method of contact*

Home

Mobile

Work

Email

Emergency Contact

Name*

Phone*

Relationship*

How did you discover our practice?*

Are you with a private health fund with dental cover?*

YES

NO

If yes, which healthfund*

Medical History

Please tick if you have any of the following conditions

*

I have NO prior medical conditions

Rheumatic Fever

Heart murmur

Liver Disease

Epilepsy

Diabetes

Radiation Therapy

AIDS / HIV

Blood Disease

Asthma

Excessive Bleeding

Respiratory Problems

Stroke

Hepatitis A / B / C

Artificial Joints

High Blood pressure

Heart condition

Low Blood pressure

Cancer/Leukemia

Please specify the year you had each condition and any other relevant details

Ladies are you Pregnant?

YES

NO

If YES how many weeks?

Other medical conditions (not listed above)

Allergies

Medications you currently take

GP Information

GP*

Practice*

Practice Phone Number*

I declare that all details provided above are correct to the best of my knowledge and belief

Signature*

Date*

DD slash MM slash YYYY

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Team

Dr. Nick Defteros
Dr. Michelle Yu
Dr. Jennifer Jom
Dr. Jakub Lazorka
Dr. Jonathan Jom
Dr. Zara Lyle
Dr Cheryl Chin
Dr. Apoorva Chavan
Dr. Dinos Kountouras

Patient Care Team

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Treatments

General Dentist

Check up and clean
Fillings
Gum Disease
Fissure Sealants
Extractions
Root Canal Treatment
Wisdom teeth
Mouthguard
Night guards / grinding
Bad breath solutions (Therabreath)
TMJ – TMD
Sleep Apnoa – SomnoMed
Happy Gas (Nitrous Oxide)

Emergency Dentist
Children’s Dentist
Cosmetic Dentist

Dental Implants
Crowns and Bridges
Dentures
Veneers
Tooth Whitening
Invisalign

No Gap Dental

No Gap Dental
Preferred Provider
CDBS Scheme
Payment Plans

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