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27 Arbour Lane, Robina Town Shopping
Centre, Robina, Gold Coast Queensland 4230

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Monday - Friday: 7.30am – 6pm
Saturday: 8am – 5pm


Address

Office Hours

Services

New Patient Form

At Robina Town Dental we strive to provide you with the highest possible care. To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present. Without this information it is difficult for your dentist or hygienist to plan your care properly.

Download the PDF version from here and bring your completed form to your appointment or you can fill it out upon arriving at our practice in just a few minutes before your appointment.

Click here to view our privacy policy.

Patient Information
Title:
Surname:* Given Name:*
Preferred Name: Date of Birth:*
Address:* Suburb:*
Postcode:*
Ph (home):* Mobile Number:
Ph (work):
E-mail:*
Vet Affairs Vet Affairs Card No:
VA Expiry Date:
Name of Private Health Fund (if any): Position No on Card:
Occupation: Employer Name:
Next of Kin
Name: Relationship: Phone:

In case of an emergency whom should we contact?

Please indicate if different to next of kin.

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.

Dental History
How long is it since your last thorough dental examination?:
Please tick any dental concerns you have?
Medical History
How do you rate your general health?
Who is your General Practitioner?:
Telephone:

Have you had or are you suffering from any of these? (please tick)

:
Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify):
What medications including natural remedies are you taking?:
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.