New Patient Questionnaire Learn about the patient experience at Switch Dental WHAT TO EXPECTNew Patient Form Fill in the form below to become a patient at Switch Dental. If you have any questions, please call us on 04 569 6808 Name(Required) First Last Preferred NameAddress(Required) Street Address City ZIP / Postal Code Phone (H)Phone (M)(Required)Email(Required) Date of birth(Required) DD slash MM slash YYYY OccupationPhone (W)Name of last DentistYear of last visitContact preference:(tick all that apply) Email Text Home phone Work phone Have you ever had:(tick all that apply) A bad dental experience Root canal therapy Hygienist treatment Tooth grinding Crown Denture/plate/false tooth Would you like to discuss any of the following:(tick all that apply) Replacing missing teeth Teeth alignment Toothache Loose teeth Botox for grinding/wrinkles Anti-snoring Tooth whitening Sports mouthguard Wisdom teeth Bleeding gums Bad breath Jaw problems Emergency contact personEmergency contact name(Required)Emergency contact number(Required)Medical HistoryYour Medical Practitioner (GP)(Required)Medical Practioner contact number(Required)Do you have a history of any of the following conditions?(tick all that apply) Arthritis Depression/Anxiety Hepatitis A/B/C/D High/low blood pressure Diabetes Osteoporosis Chest problems/COPD/Asthma Drug/alcohol dependence Cold sores Heart problems Bleeding problems/Anaemia Gastric problems/kidney problems Cancer Rheumatic fever Epilepsy/Fits/Fainting Any other medical conditions (please specify) Other medical conditions:Please select if yes to any of the following:(tick all that apply) Do you have any food, drug or other allergies? (please specify) Have you been hospitalised in the past two years? (please specify) Have you had any prosthetic surgery? (e.g. heart valve, stent, joint replacement, pacemaker etc.) Have you had a stroke within the past 2 years? Are you HIV positive? Female only: Are you pregnant or breastfeeding? Are you regularly taking any medicine, tablets, capsules or drugs? (please specify) Have you taken Fosamax in the past two years? Are you currently taking any blood thinners? Allergies:Details of hospitalisation:Medications:How did you hear about us?(tick all that apply) Google / website Street sign Bee Healthy Friend / referral Other (please specify) How did you hear about us?Is there anything else you'd like to share with us?CAPTCHA Ready to Get Started?Book your comprehensive new-patient exam today. It’s an honest, respectful way to get the clarity you deserve with zero pressure.BOOK ONLINE
